1760708218 NPI number — DAVID J RALLIS DDS MD ORAL AND MAXILLOFACIAL SURGERY, PC

Table of content: (NPI 1760708218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760708218 NPI number — DAVID J RALLIS DDS MD ORAL AND MAXILLOFACIAL SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID J RALLIS DDS MD ORAL AND MAXILLOFACIAL SURGERY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760708218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4110 A STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-327-9400
Provider Business Mailing Address Fax Number:
402-327-9401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4110 A STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-327-9400
Provider Business Practice Location Address Fax Number:
402-327-9401
Provider Enumeration Date:
04/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
RALLIS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
507-358-0974

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  25504 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204E00000X , with the licence number: 6487 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10025849700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com