Provider Demographics
NPI:1952623902
Name:DENTAL SPECIALTIES
Entity Type:Organization
Organization Name:DENTAL SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:RAKES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-895-1900
Mailing Address - Street 1:14133 Q ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137
Mailing Address - Country:US
Mailing Address - Phone:402-895-1900
Mailing Address - Fax:402-895-5726
Practice Address - Street 1:14133 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137
Practice Address - Country:US
Practice Address - Phone:402-895-1900
Practice Address - Fax:402-895-5726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE67121223G0001X
NE48791223P0221X
NE63351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025232300Medicaid