Provider Demographics
NPI:1184708422
Name:POWELL, TANYA WANDA (DDS)
Entity type:Individual
Prefix:MISS
First Name:TANYA
Middle Name:WANDA
Last Name:POWELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:TANYA
Other - Middle Name:WANDA
Other - Last Name:KORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:249 CHERRY HILL BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510
Mailing Address - Country:US
Mailing Address - Phone:402-488-2383
Mailing Address - Fax:402-488-2384
Practice Address - Street 1:249 CHERRY HILL BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510
Practice Address - Country:US
Practice Address - Phone:402-488-2383
Practice Address - Fax:402-488-2384
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE63211223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100249672-00Medicaid
NE05691OtherBLUECROSS BLUESHIELD