MEDICARE: NOLAND WILLIAM BROEKEMIER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	7467	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H13204619	OTHER	NE	DRIVER'S LICENSE

General Provider Information

NPI Number	:	1265925853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOLAND WILLIAM BROEKEMIER DDS

Provider Business Mailing Address
First Line	:	3157 FARNAM ST APT 7618
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68131-3548
Country	:	US
Telephone Number	:	308-940-2821
Fax Number	:

Provider Business Practice Location Address
First Line	:	11110 FORT ST STE 106
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68164-2183
Country	:	US
Telephone Number	:	402-492-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2018
Last Update Date	:	06/08/2018

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