Provider Demographics
NPI:1962713107
Name:O'MALLEY, ROBERT JOHN
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14801 W CENTER RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3298
Mailing Address - Country:US
Mailing Address - Phone:402-330-2007
Mailing Address - Fax:402-330-2594
Practice Address - Street 1:14801 W CENTER RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3298
Practice Address - Country:US
Practice Address - Phone:402-330-2007
Practice Address - Fax:402-330-2594
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE68861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice