Provider Demographics
NPI:1417216722
Name:DR. MARK VANICEK
Entity Type:Organization
Organization Name:DR. MARK VANICEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:VANICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-420-2600
Mailing Address - Street 1:7621 KENNELLEY DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3797
Mailing Address - Country:US
Mailing Address - Phone:402-420-2600
Mailing Address - Fax:
Practice Address - Street 1:6101 VILLAGE DR STE 102
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5830
Practice Address - Country:US
Practice Address - Phone:402-420-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5311261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental