Provider Demographics
NPI:1669239612
Name:NOMAD DENTAL SPECIALIST
Entity type:Organization
Organization Name:NOMAD DENTAL SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-833-2740
Mailing Address - Street 1:6337 TULIP LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-3829
Mailing Address - Country:US
Mailing Address - Phone:404-287-8120
Mailing Address - Fax:
Practice Address - Street 1:6337 TULIP LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-3829
Practice Address - Country:US
Practice Address - Phone:045-148-1204
Practice Address - Fax:833-415-1902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty