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General NPI Number Information
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NPI Number | 1568682052
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Entity Type | Organization
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Legal Business Name | WILDERNESS STATION PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 04/26/2007
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Last Update Date | 12/23/2014
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Provider Practice Location Address
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Address Line | 8020 S 13TH ST
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City | LINCOLN
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State | NE
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Zip | 68512-9371
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Country | US
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Telephone | 402-420-8020
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Fax | 402-420-0367
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Provider Business Mailing Address
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Address Line | 8020 S 13TH ST
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City | LINCOLN
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State | NE
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Zip | 68512-9371
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Country | US
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Telephone | 402-420-8020
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Fax | 402-420-0367
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. MARTIN D. KILLEEN
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Credential | DDS
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Telephone | 402-420-8020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 6492
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License Number State | NE
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