Healthcare Provider Details

I. General information

NPI: 1891069043
Provider Name (Legal Business Name): MARK PANNETON DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9731 GILES RD
LA VISTA NE
68128-2930
US

IV. Provider business mailing address

9731 GILES RD
LA VISTA NE
68128-2930
US

V. Phone/Fax

Practice location:
  • Phone: 402-537-4620
  • Fax: 402-537-4346
Mailing address:
  • Phone: 402-537-4620
  • Fax: 402-537-4346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5527
License Number StateNE

VIII. Authorized Official

Name: MARK J PANNETON
Title or Position: OWNER
Credential: DDS
Phone: 402-537-4620