Provider Demographics
NPI:1912079781
Name:PIONEER WOODS DENTAL LLC
Entity type:Organization
Organization Name:PIONEER WOODS DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:QUINCY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-447-6042
Mailing Address - Street 1:POB 87
Mailing Address - Street 2:314 N 4TH ST
Mailing Address - City:NEWMAN GROVE
Mailing Address - State:NE
Mailing Address - Zip Code:68758-0087
Mailing Address - Country:US
Mailing Address - Phone:402-447-6042
Mailing Address - Fax:402-447-6009
Practice Address - Street 1:4210 PIONEER WOODS DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506
Practice Address - Country:US
Practice Address - Phone:402-484-6042
Practice Address - Fax:402-484-6043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE58761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025209600Medicaid