Provider Demographics
NPI:1457344178
Name:CREIGHTON UNIVERSITY
Entity Type:Organization
Organization Name:CREIGHTON UNIVERSITY
Other - Org Name:CREIGHTON SURGICAL ORAL PATHOLOGY SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-280-5020
Mailing Address - Street 1:2500 CALIFORNIA PLZ
Mailing Address - Street 2:SCHOOL OF DENTISTRY
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68178-0001
Mailing Address - Country:US
Mailing Address - Phone:402-280-5020
Mailing Address - Fax:402-280-5094
Practice Address - Street 1:2500 CALIFORNIA PLZ
Practice Address - Street 2:SCHOOL OF DENTISTRY
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68178-0001
Practice Address - Country:US
Practice Address - Phone:402-280-5020
Practice Address - Fax:402-280-5094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
05338OtherBCBS