Provider Demographics
NPI:1912376617
Name:GOOD LIFE DENTAL, P.C.
Entity Type:Organization
Organization Name:GOOD LIFE DENTAL, P.C.
Other - Org Name:COMPREHENSIVE FAMILY DENTISTRY, L.L.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFORD WAWRZYNKIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-532-0427
Mailing Address - Street 1:302 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5407
Practice Address - Country:US
Practice Address - Phone:308-532-0427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7079261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE261QD0000XMedicaid