Provider Demographics
NPI:1972861847
Name:MARANATHA DENTAL GROUP
Entity Type:Organization
Organization Name:MARANATHA DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:DWORAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-489-3837
Mailing Address - Street 1:1600 S 70TH ST
Mailing Address - Street 2:STE 200
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1568
Mailing Address - Country:US
Mailing Address - Phone:402-489-3837
Mailing Address - Fax:402-489-3931
Practice Address - Street 1:1600 S. 70TH ST.
Practice Address - Street 2:STE 200
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1568
Practice Address - Country:US
Practice Address - Phone:402-489-3837
Practice Address - Fax:402-489-3931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4314122300000X
NE6116122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47063464200Medicaid