Provider Demographics
NPI:1265306047
Name:WEST PACIFIC DENTAL GROUP
Entity type:Organization
Organization Name:WEST PACIFIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:LYSNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-697-0765
Mailing Address - Street 1:1201 S 157TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-4910
Mailing Address - Country:US
Mailing Address - Phone:402-697-0765
Mailing Address - Fax:402-502-9754
Practice Address - Street 1:1201 S 157TH ST STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-4910
Practice Address - Country:US
Practice Address - Phone:402-697-0765
Practice Address - Fax:402-502-9754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty