Provider Demographics
NPI:1710056056
Name:VANICEK, MARK LEROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEROY
Last Name:VANICEK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 VILLAGE DR
Mailing Address - Street 2:STE 102
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5830
Mailing Address - Country:US
Mailing Address - Phone:402-420-2600
Mailing Address - Fax:402-420-2963
Practice Address - Street 1:6101 VILLAGE DR
Practice Address - Street 2:STE 102
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5830
Practice Address - Country:US
Practice Address - Phone:402-420-2600
Practice Address - Fax:402-420-2963
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE53111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE05649OtherBLUE CROSS BLUE SHIELD
NE47076193500Medicaid