Provider Demographics
NPI:1174544357
Name:OMNI DENTAL CENTRES, LLP
Entity type:Organization
Organization Name:OMNI DENTAL CENTRES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:HURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-347-6151
Mailing Address - Street 1:3004 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CARTER LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51510-1438
Mailing Address - Country:US
Mailing Address - Phone:712-347-6151
Mailing Address - Fax:712-847-0164
Practice Address - Street 1:1026 WOODBURY AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-7915
Practice Address - Country:US
Practice Address - Phone:712-328-8573
Practice Address - Fax:712-328-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA81321223G0001X
IA68551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
628884OtherUNITED CONCORDIA
IA20363OtherBLUE CROSS BLUE SHIELD
NE07881OtherBLUE CROSS BLUE SHIELD