Provider Demographics
NPI:1942681978
Name:PREMIER SMILE DENTAL ASSOCIATION PC
Entity Type:Organization
Organization Name:PREMIER SMILE DENTAL ASSOCIATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-300-0506
Mailing Address - Street 1:56470 HIGHWAY 4
Mailing Address - Street 2:
Mailing Address - City:DAYKIN
Mailing Address - State:NE
Mailing Address - Zip Code:68338-3033
Mailing Address - Country:US
Mailing Address - Phone:402-300-0506
Mailing Address - Fax:
Practice Address - Street 1:17110 LAKESIDE HILLS PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-5600
Practice Address - Country:US
Practice Address - Phone:402-300-0506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7222122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty