Provider Demographics
NPI:1619529617
Name:MATULKA, BRENTON JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:JOSEPH
Last Name:MATULKA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 FALLBROOK BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-9040
Mailing Address - Country:US
Mailing Address - Phone:402-467-0007
Mailing Address - Fax:
Practice Address - Street 1:575 FALLBROOK BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-9040
Practice Address - Country:US
Practice Address - Phone:402-467-0007
Practice Address - Fax:402-476-7873
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE75751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice