Provider Demographics
NPI:1710311162
Name:PELNAR, MIKAYLA MARIE (PHRDH)
Entity Type:Individual
Prefix:MS
First Name:MIKAYLA
Middle Name:MARIE
Last Name:PELNAR
Suffix:
Gender:F
Credentials:PHRDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16404 S. 99TH ST
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046
Mailing Address - Country:US
Mailing Address - Phone:402-515-3682
Mailing Address - Fax:
Practice Address - Street 1:16404 S. 99TH ST
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046
Practice Address - Country:US
Practice Address - Phone:402-515-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2050124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026350100Medicaid