Healthcare Provider Details

I. General information

NPI: 1225070410
Provider Name (Legal Business Name): MARTIN D KILLEEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 S 13TH ST
LINCOLN NE
68512-9371
US

IV. Provider business mailing address

8020 S 13TH ST
LINCOLN NE
68512-9371
US

V. Phone/Fax

Practice location:
  • Phone: 402-421-8020
  • Fax: 402-421-1320
Mailing address:
  • Phone: 402-421-8020
  • Fax: 402-421-1320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6492
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: