MEDICARE: DR. JUSTIN TYLER DWORAK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6116	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366458382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN TYLER DWORAK DDS

Provider Business Mailing Address
First Line	:	1600 S 70TH ST
Second Line	:	STE 200
City	:	LINCOLN
State	:	NE
Zip	:	68506-1568
Country	:	US
Telephone Number	:	402-489-3837
Fax Number	:	402-489-3931

Provider Business Practice Location Address
First Line	:	1600 S 70TH ST
Second Line	:	STE 200
City	:	LINCOLN
State	:	NE
Zip	:	68506-1568
Country	:	US
Telephone Number	:	402-489-3837
Fax Number	:	402-489-3931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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