MEDICARE: NORTHEAST FAMILY DENTAL LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1578938122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	1719 N COTNER BLVD
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68505-1356
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1719 N COTNER BLVD
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68505-1356
Country	:	US
Telephone Number	:	402-420-7045
Fax Number	:

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	BONNIE GALL
Credential	:
Telephone Number	:	402-904-6005

Provider Enumeration Date	:	12/08/2015
Last Update Date	:	12/08/2015

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Directions to “NORTHEAST FAMILY DENTAL LLC ” Practice Location

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