Provider Demographics
NPI:1366213258
Name:SEDILLO MOBILE DDS NE LLC
Entity type:Organization
Organization Name:SEDILLO MOBILE DDS NE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:OLIVARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-326-4860
Mailing Address - Street 1:5884 HIGH PASTURE DR
Mailing Address - Street 2:
Mailing Address - City:FORT CALHOUN
Mailing Address - State:NE
Mailing Address - Zip Code:68023-8201
Mailing Address - Country:US
Mailing Address - Phone:402-237-2163
Mailing Address - Fax:
Practice Address - Street 1:5884 HIGH PASTURE DR
Practice Address - Street 2:
Practice Address - City:FORT CALHOUN
Practice Address - State:NE
Practice Address - Zip Code:68023-8201
Practice Address - Country:US
Practice Address - Phone:402-237-2163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental