Provider Demographics
NPI:1831599158
Name:DUDZINSKI DENTAL PC
Entity type:Organization
Organization Name:DUDZINSKI DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-341-5306
Mailing Address - Street 1:2002 VINTON ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68108-1921
Mailing Address - Country:US
Mailing Address - Phone:402-341-5306
Mailing Address - Fax:402-346-1905
Practice Address - Street 1:17404 BURKE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2239
Practice Address - Country:US
Practice Address - Phone:402-493-2112
Practice Address - Fax:402-493-8399
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STOP DECAY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-25
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1598992026Medicaid
NE47064716913Medicaid