1912079781 NPI number — PIONEER WOODS DENTAL LLC

Table of content: (NPI 1912079781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912079781 NPI number — PIONEER WOODS DENTAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIONEER WOODS DENTAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PIONEER WOODS DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912079781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
POB 87
Provider Second Line Business Mailing Address:
314 N 4TH ST
Provider Business Mailing Address City Name:
NEWMAN GROVE
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68758-0087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-447-6042
Provider Business Mailing Address Fax Number:
402-447-6009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4210 PIONEER WOODS DRIVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-484-6042
Provider Business Practice Location Address Fax Number:
402-484-6043
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
QUINCY
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
402-447-6042

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5876 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10025209600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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