Provider Demographics
NPI:1336290824
Name:PRAIRIE DENTAL GROUP LLC
Entity Type:Organization
Organization Name:PRAIRIE DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-483-7595
Mailing Address - Street 1:6944 A ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-4112
Mailing Address - Country:US
Mailing Address - Phone:402-483-7597
Mailing Address - Fax:
Practice Address - Street 1:6944 A ST
Practice Address - Street 2:SUITE B
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4112
Practice Address - Country:US
Practice Address - Phone:402-483-7597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6673122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty