Provider Demographics
NPI:1073811014
Name:SHADOW RIDGE DENTAL
Entity Type:Organization
Organization Name:SHADOW RIDGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-933-0525
Mailing Address - Street 1:19103 MASON PLZ
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-5659
Mailing Address - Country:US
Mailing Address - Phone:402-933-0525
Mailing Address - Fax:402-933-2925
Practice Address - Street 1:19103 MASON PLZ
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-5659
Practice Address - Country:US
Practice Address - Phone:402-933-0525
Practice Address - Fax:402-933-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE47911223G0001X
NE44881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100251659-00Medicaid