Provider Demographics
NPI:1356772420
Name:LINCOLN AESTHETIC & RECONSTRUCTIVE SURGERY PC
Entity type:Organization
Organization Name:LINCOLN AESTHETIC & RECONSTRUCTIVE SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:402-435-0044
Mailing Address - Street 1:2222 S 16TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3785
Mailing Address - Country:US
Mailing Address - Phone:402-435-0044
Mailing Address - Fax:
Practice Address - Street 1:2222 S 16TH ST STE 300
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3785
Practice Address - Country:US
Practice Address - Phone:402-435-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE55041223S0112X
NE18887208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NEF50473Medicare UPIN