Provider Demographics
NPI:1922525450
Name:SOUTH LINCOLN DENTAL LLC
Entity Type:Organization
Organization Name:SOUTH LINCOLN DENTAL LLC
Other - Org Name:WILLIAMSBURG DENTAL - SOUTH STREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-904-6005
Mailing Address - Street 1:WILLIAMSBURG DENTAL SOUTH STREET
Mailing Address - Street 2:6930 L STREET SUITE B
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510
Mailing Address - Country:US
Mailing Address - Phone:402-904-6005
Mailing Address - Fax:
Practice Address - Street 1:1265 S COTNER BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4975
Practice Address - Country:US
Practice Address - Phone:402-904-6005
Practice Address - Fax:402-904-6005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH LINCOLN DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE71781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty