Provider Demographics
NPI:1700078961
Name:40TH AND DODGE FAMILY DENTISTRY, PC
Entity Type:Organization
Organization Name:40TH AND DODGE FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:I FEN
Authorized Official - Middle Name:'JENNIFER'
Authorized Official - Last Name:HOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-763-8998
Mailing Address - Street 1:111 N 40TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2356
Mailing Address - Country:US
Mailing Address - Phone:402-763-8998
Mailing Address - Fax:402-614-4812
Practice Address - Street 1:111 N 40TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2356
Practice Address - Country:US
Practice Address - Phone:402-763-8998
Practice Address - Fax:402-614-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty