Healthcare Provider Details

I. General information

NPI: 1770039265
Provider Name (Legal Business Name): EAST LINCOLN DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6930 L ST SUITE B
LINCOLN NE
68510-2411
US

IV. Provider business mailing address

6040 VILLAGE DR SUITE B
LINCOLN NE
68516-6640
US

V. Phone/Fax

Practice location:
  • Phone: 402-489-6547
  • Fax: 402-420-7045
Mailing address:
  • Phone: 402-420-2222
  • Fax: 402-420-7045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5965
License Number StateNE

VIII. Authorized Official

Name: BONNIE GALL
Title or Position: OFFICE MANAGER
Credential:
Phone: 402-904-6005