Provider Demographics
NPI:1255737078
Name:PLATTE VALLEY ORAL & MAXILLOFACIAL SURGERY LLC
Entity type:Organization
Organization Name:PLATTE VALLEY ORAL & MAXILLOFACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-633-1760
Mailing Address - Street 1:416 VALLEY VIEW DRIVE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NC
Mailing Address - Zip Code:69361-1420
Mailing Address - Country:US
Mailing Address - Phone:308-633-1760
Mailing Address - Fax:308-633-1762
Practice Address - Street 1:416 VALLEY VIEW DRIVE
Practice Address - Street 2:SUITE 800
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NC
Practice Address - Zip Code:69361-1420
Practice Address - Country:US
Practice Address - Phone:308-633-1760
Practice Address - Fax:308-633-1762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty