Provider Demographics
NPI:1831326826
Name:OMALEE DENTAL LLC
Entity type:Organization
Organization Name:OMALEE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:229-838-4203
Mailing Address - Street 1:14 SIXTH AVE BOX 200
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:GA
Mailing Address - Zip Code:31821
Mailing Address - Country:US
Mailing Address - Phone:229-838-4203
Mailing Address - Fax:229-838-4204
Practice Address - Street 1:14 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:GA
Practice Address - Zip Code:31821
Practice Address - Country:US
Practice Address - Phone:229-838-4203
Practice Address - Fax:229-838-4204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010226261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental