Provider Demographics
NPI:1639259856
Name:PHELPS, LANNAE LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:LANNAE
Middle Name:LYNN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 TANNER CT
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-0333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 S JEFFERS ST
Practice Address - Street 2:SUITE #1
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5371
Practice Address - Country:US
Practice Address - Phone:308-534-4040
Practice Address - Fax:308-534-1087
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE65571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025389900Medicaid