Healthcare Provider Details

I. General information

NPI: 1376294298
Provider Name (Legal Business Name): MPDA BROKEN BOW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 SOUTH E SUITE 5
BROKEN BOW NE
68822
US

IV. Provider business mailing address

2021 SOUTH E SUITE 5
BROKEN BOW NE
68822
US

V. Phone/Fax

Practice location:
  • Phone: 308-767-2004
  • Fax: 308-767-2006
Mailing address:
  • Phone: 308-767-2004
  • Fax: 308-767-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN ALLEN LASHLEY
Title or Position: SOLE MEMBER
Credential: DDS
Phone: 308-534-1289