Provider Demographics
NPI:1528635497
Name:RORK, MITCHELL (DDS)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:RORK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9961 S 168TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-4232
Mailing Address - Country:US
Mailing Address - Phone:402-614-4017
Mailing Address - Fax:
Practice Address - Street 1:9961 S 168TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68136-4232
Practice Address - Country:US
Practice Address - Phone:402-614-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-099501223G0001X
NE77221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice