Provider Demographics
NPI:1932233095
Name:INNOVATIVE DENTAL, P.C.
Entity type:Organization
Organization Name:INNOVATIVE DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-933-8005
Mailing Address - Street 1:13625 CALIFORNIA ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-5233
Mailing Address - Country:US
Mailing Address - Phone:402-933-8005
Mailing Address - Fax:402-504-1338
Practice Address - Street 1:13625 CALIFORNIA ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5233
Practice Address - Country:US
Practice Address - Phone:402-933-8005
Practice Address - Fax:402-504-1338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE65211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025440200Medicaid