Provider Demographics
NPI:1679653661
Name:TRI-VALLEY DENTAL P.C.
Entity type:Organization
Organization Name:TRI-VALLEY DENTAL P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:WENTWORTH
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-727-9292
Mailing Address - Street 1:1689 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2435
Mailing Address - Country:US
Mailing Address - Phone:402-727-9292
Mailing Address - Fax:402-727-9299
Practice Address - Street 1:1689 E 23RD ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2435
Practice Address - Country:US
Practice Address - Phone:402-727-9292
Practice Address - Fax:402-727-9299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE39561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid