=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598738643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 N CUSTER AVE
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-384-0534
-----------------------------------------------------
Fax | 308-384-4094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 N CUSTER AVE
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-384-0534
-----------------------------------------------------
Fax | 308-384-4094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SEC TREAS
-----------------------------------------------------
Name | DR. LESLEY T BOWDEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 308-384-0534
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------