Provider Demographics
NPI:1568682052
Name:WILDERNESS STATION PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:WILDERNESS STATION PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KILLEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-420-8020
Mailing Address - Street 1:8020 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68512-9371
Mailing Address - Country:US
Mailing Address - Phone:402-420-8020
Mailing Address - Fax:402-420-0367
Practice Address - Street 1:8020 S 13TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-9371
Practice Address - Country:US
Practice Address - Phone:402-420-8020
Practice Address - Fax:402-420-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6492261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025264500Medicaid