Provider Demographics
NPI:1598725129
Name:PANNETON, MARK JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:PANNETON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18140 BURKE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-4433
Mailing Address - Country:US
Mailing Address - Phone:402-934-5200
Mailing Address - Fax:402-537-4346
Practice Address - Street 1:18140 BURKE ST STE 100
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-4433
Practice Address - Country:US
Practice Address - Phone:402-934-5200
Practice Address - Fax:402-537-4346
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE55271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47083904100Medicaid