Provider Demographics
NPI:1376294298
Name:MPDA BROKEN BOW LLC
Entity Type:Organization
Organization Name:MPDA BROKEN BOW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-534-1289
Mailing Address - Street 1:2021 SOUTH E
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822
Mailing Address - Country:US
Mailing Address - Phone:308-767-2004
Mailing Address - Fax:308-767-2006
Practice Address - Street 1:2021 SOUTH E
Practice Address - Street 2:SUITE 5
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822
Practice Address - Country:US
Practice Address - Phone:308-767-2004
Practice Address - Fax:308-767-2006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty