Provider Demographics
NPI:1720144967
Name:LEGACY DENTAL P.C.
Entity Type:Organization
Organization Name:LEGACY DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:TRACY
Authorized Official - Last Name:BRIGDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-393-1108
Mailing Address - Street 1:17602 WRIGHT ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2097
Mailing Address - Country:US
Mailing Address - Phone:402-393-1108
Mailing Address - Fax:402-393-1184
Practice Address - Street 1:17602 WRIGHT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2097
Practice Address - Country:US
Practice Address - Phone:402-393-1108
Practice Address - Fax:402-393-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE59691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty