Provider Demographics
NPI:1831338938
Name:PERSONAL FAMILY DENTISTRY, P.C.
Entity type:Organization
Organization Name:PERSONAL FAMILY DENTISTRY, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-247-3381
Mailing Address - Street 1:302 COUNTY ROAD
Mailing Address - Street 2:
Mailing Address - City:MORRILL
Mailing Address - State:NE
Mailing Address - Zip Code:69358
Mailing Address - Country:US
Mailing Address - Phone:308-247-3381
Mailing Address - Fax:308-247-2809
Practice Address - Street 1:302 COUNTY RD
Practice Address - Street 2:
Practice Address - City:MORRILL
Practice Address - State:NE
Practice Address - Zip Code:69358-4526
Practice Address - Country:US
Practice Address - Phone:308-247-3381
Practice Address - Fax:308-247-2809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE264304Medicare PIN