Provider Demographics
NPI:1306055504
Name:LANNAE PHELPS D.D.S., P.C.
Entity type:Organization
Organization Name:LANNAE PHELPS D.D.S., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANNAE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-534-4040
Mailing Address - Street 1:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69103-0846
Mailing Address - Country:US
Mailing Address - Phone:308-534-4040
Mailing Address - Fax:308-534-1087
Practice Address - Street 1:221 S JEFFERS ST
Practice Address - Street 2:SUITE #1
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5371
Practice Address - Country:US
Practice Address - Phone:308-534-4040
Practice Address - Fax:308-534-1087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE65571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025389900Medicaid