Provider Demographics
NPI:1538172192
Name:3D DENTAL PC
Entity type:Organization
Organization Name:3D DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEWISPELARE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-614-0322
Mailing Address - Street 1:17853 PIERCE PLAZA
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130
Mailing Address - Country:US
Mailing Address - Phone:402-614-0322
Mailing Address - Fax:402-991-4608
Practice Address - Street 1:17853 PIERCE PLAZA
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130
Practice Address - Country:US
Practice Address - Phone:402-614-0322
Practice Address - Fax:402-991-4608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6173122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025228900Medicaid