Provider Demographics
NPI:1700292588
Name:ISKE, BENJAMIN ROBERT
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:ISKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NE
Mailing Address - Zip Code:69336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1006 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NE
Practice Address - Zip Code:69336-4035
Practice Address - Country:US
Practice Address - Phone:308-262-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026535400Medicaid