Healthcare Provider Details

I. General information

NPI: 1023170628
Provider Name (Legal Business Name): PAUL EDWARD BACINO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date: 08/10/2012
Reactivation Date: 03/13/2013

III. Provider practice location address

132 SOUTH STARK ST
BENNINGTON NE
68007-0166
US

IV. Provider business mailing address

PO BOX 166
BENNINGTON NE
68007-0166
US

V. Phone/Fax

Practice location:
  • Phone: 402-238-2434
  • Fax: 402-238-3230
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4986
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: