Provider Demographics
NPI:1194884296
Name:FAMILY AND COSMETIC DENTISTRY PC
Entity type:Organization
Organization Name:FAMILY AND COSMETIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-334-8208
Mailing Address - Street 1:12518 A STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4137
Mailing Address - Country:US
Mailing Address - Phone:402-330-8216
Mailing Address - Fax:
Practice Address - Street 1:11836 ELM STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4439
Practice Address - Country:US
Practice Address - Phone:402-334-8208
Practice Address - Fax:402-334-1106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty