Provider Demographics
NPI:1083973671
Name:KERSENBROCK DENTAL CARE LLC
Entity Type:Organization
Organization Name:KERSENBROCK DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KERSENBROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-336-4211
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:O'NEILL
Mailing Address - State:NE
Mailing Address - Zip Code:68763-0189
Mailing Address - Country:US
Mailing Address - Phone:402-336-4211
Mailing Address - Fax:402-336-3905
Practice Address - Street 1:430 E. EVERETT ST.
Practice Address - Street 2:
Practice Address - City:O'NEILL
Practice Address - State:NE
Practice Address - Zip Code:68763-1838
Practice Address - Country:US
Practice Address - Phone:402-336-4211
Practice Address - Fax:402-336-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE49711223G0001X
NE69031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025832300Medicaid