Provider Demographics
NPI:1982860649
Name:GRAND ISLAND DENTAL CENTER, LLC, PC
Entity Type:Organization
Organization Name:GRAND ISLAND DENTAL CENTER, LLC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EQUAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-382-7813
Mailing Address - Street 1:2414 W FAIDLEY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4368
Mailing Address - Country:US
Mailing Address - Phone:308-382-7813
Mailing Address - Fax:308-385-0370
Practice Address - Street 1:2414 W FAIDLEY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4368
Practice Address - Country:US
Practice Address - Phone:308-382-7813
Practice Address - Fax:308-385-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty