Healthcare Provider Details

I. General information

NPI: 1285987735
Provider Name (Legal Business Name): PONCA TRIBE OF NEBRASKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 SYRACUSE AVE
NORFOLK NE
68701-2458
US

IV. Provider business mailing address

1800 SYRACUSE AVE
NORFOLK NE
68701-2458
US

V. Phone/Fax

Practice location:
  • Phone: 402-371-8834
  • Fax: 402-371-7564
Mailing address:
  • Phone: 402-371-8834
  • Fax: 402-731-7564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD LEE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 402-734-5275