Provider Demographics
NPI:1235579533
Name:SERBOUSEK, MATTHEW (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:SERBOUSEK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-1547
Mailing Address - Country:US
Mailing Address - Phone:308-340-2568
Mailing Address - Fax:
Practice Address - Street 1:638 N WEBB RD STE 1
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4057
Practice Address - Country:US
Practice Address - Phone:308-340-2568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist