Provider Demographics
NPI:1437515111
Name:CRETE FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:CRETE FAMILY DENTAL, LLC
Other - Org Name:CRETE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-904-6005
Mailing Address - Street 1:6040 VILLAGE DR
Mailing Address - Street 2:STE 1
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-6640
Mailing Address - Country:US
Mailing Address - Phone:402-420-2222
Mailing Address - Fax:402-420-7045
Practice Address - Street 1:1005 E. HIGHWAY 33
Practice Address - Street 2:SUITE 7
Practice Address - City:CRETE
Practice Address - State:NE
Practice Address - Zip Code:68333-2546
Practice Address - Country:US
Practice Address - Phone:402-418-7214
Practice Address - Fax:402-420-7045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE71781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty