Provider Demographics
NPI:1154970655
Name:ADVANCED ORAL SURGERY, PLLC
Entity type:Organization
Organization Name:ADVANCED ORAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRITTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-934-8999
Mailing Address - Street 1:5040 S 153RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5067
Mailing Address - Country:US
Mailing Address - Phone:402-934-8999
Mailing Address - Fax:
Practice Address - Street 1:3265 S 24TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-6901
Practice Address - Country:US
Practice Address - Phone:402-934-8999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty