Provider Demographics
NPI:1720158280
Name:SOLOMON, STACY LEIGH (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LEIGH
Last Name:SOLOMON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 S E ST
Mailing Address - Street 2:STE #5
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-1848
Mailing Address - Country:US
Mailing Address - Phone:308-767-2004
Mailing Address - Fax:308-767-2006
Practice Address - Street 1:2021 S E ST
Practice Address - Street 2:STE #5
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-1848
Practice Address - Country:US
Practice Address - Phone:308-767-2004
Practice Address - Fax:308-767-2006
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE65151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE05178OtherBCBS
NE10025242100Medicaid