Provider Demographics
NPI:1427500859
Name:LEGACY DENTAL CARE, LLC
Entity type:Organization
Organization Name:LEGACY DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:JAMISON
Authorized Official - Last Name:RISING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-799-6453
Mailing Address - Street 1:14406 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68138-6521
Mailing Address - Country:US
Mailing Address - Phone:402-333-1120
Mailing Address - Fax:402-697-8713
Practice Address - Street 1:17602 WRIGHT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2097
Practice Address - Country:US
Practice Address - Phone:402-393-1108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRENT J. RISING, DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE68121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty