Provider Demographics
NPI:1043727092
Name:WILLIAMSBURG DENTAL LLC
Entity type:Organization
Organization Name:WILLIAMSBURG DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-904-6005
Mailing Address - Street 1:6930 L ST STE B
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2456
Mailing Address - Country:US
Mailing Address - Phone:402-904-6005
Mailing Address - Fax:
Practice Address - Street 1:1265 S COTNER BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4975
Practice Address - Country:US
Practice Address - Phone:402-420-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAMSBURG DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE59651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE51070558700Medicaid