Provider Demographics
NPI:1992097778
Name:SE NEBRASKA DENTAL GROUP, PC
Entity type:Organization
Organization Name:SE NEBRASKA DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:NEUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-267-2325
Mailing Address - Street 1:105 W ELDORA AVE
Mailing Address - Street 2:P.O. BOX 403
Mailing Address - City:WEEPING WATER
Mailing Address - State:NE
Mailing Address - Zip Code:68463-4201
Mailing Address - Country:US
Mailing Address - Phone:402-267-2325
Mailing Address - Fax:402-267-2725
Practice Address - Street 1:105 W ELDORA AVE
Practice Address - Street 2:
Practice Address - City:WEEPING WATER
Practice Address - State:NE
Practice Address - Zip Code:68463-4201
Practice Address - Country:US
Practice Address - Phone:402-267-2325
Practice Address - Fax:402-267-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6172122300000X
NE6707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025741800Medicaid