Provider Demographics
NPI:1609106012
Name:NEBEKER, CORDELL DENTON (DDS, MS)
Entity Type:Individual
Prefix:
First Name:CORDELL
Middle Name:DENTON
Last Name:NEBEKER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 CLOCKTOWER AVE.
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607
Mailing Address - Country:US
Mailing Address - Phone:208-453-6188
Mailing Address - Fax:
Practice Address - Street 1:4111 CLOCKTOWER AVE.
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607
Practice Address - Country:US
Practice Address - Phone:208-453-6188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4483-PD1223P0221X
UT8147013-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry