Provider Demographics
NPI:1043499387
Name:PERSHING, JOHN KEITH JR (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEITH
Last Name:PERSHING
Suffix:JR
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:624 N MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5210
Mailing Address - Country:US
Mailing Address - Phone:402-462-4173
Mailing Address - Fax:402-462-5516
Practice Address - Street 1:624 N MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5210
Practice Address - Country:US
Practice Address - Phone:402-462-4173
Practice Address - Fax:402-462-5516
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE42621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-057524801Medicaid