Healthcare Provider Details

I. General information

NPI: 1912376617
Provider Name (Legal Business Name): GOOD LIFE DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S BAILEY AVE
NORTH PLATTE NE
69101-5407
US

IV. Provider business mailing address

302 S BAILEY AVE
NORTH PLATTE NE
69101-5407
US

V. Phone/Fax

Practice location:
  • Phone: 308-532-0427
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7079
License Number StateNE

VIII. Authorized Official

Name: KATE WOLFORD WAWRZYNKIEWICZ
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 308-532-0427