Provider Demographics
NPI:1154750677
Name:PEDIATRIC DENTISTRY, P.C.
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-423-3322
Mailing Address - Street 1:3901 PINE LAKE RD STE 250
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5497
Mailing Address - Country:US
Mailing Address - Phone:402-423-3322
Mailing Address - Fax:
Practice Address - Street 1:3901 PINE LAKE RD STE 250
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5497
Practice Address - Country:US
Practice Address - Phone:402-423-3322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2018-12-12
Deactivation Date:2013-11-08
Deactivation Code:
Reactivation Date:2018-12-12
Provider Licenses
StateLicense IDTaxonomies
NE6566261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025649100Medicaid