Basic Information
| Provider Information | |||||||||
| NPI: | 1962590877 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENDT | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1437 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027213600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13215 BIRCH DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681645431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023900770 | ||||||||
| FaxNumber: | 4023971074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 18252 | NE | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 47052802413 | 05 | NE | MEDICAID |