Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 25465 | NE |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 25465 | NE |
NPI | 1164686648 |
---|---|
Provider Name | Dr. Jason Bradford Untrauer |
First Address | Omaha, NE 68198-8102 |
Second Address | Omaha, NE 68105-1053 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2008 |
Last Update Date | 29/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
25465 | NE LICENSE (01) | NE |