NPIMap

Organization Active NPI

Shadow Ridge Dental

  • General Practice Dentistry
  • Elkhorn, NE
National Provider Identifier
1073811014
Registry record updated Feb 28, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
4791 Issued in NE
Legal business name
SHADOW RIDGE DENTAL
Practice address
19103 Mason PLZ
Elkhorn, NE 68022-5659
Phone
(402) 933-0525
Fax
(402) 933-2925
NPI assigned
Feb 28, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 28, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
James W Becker, DDS
Title
Owner
Phone
(402) 933-0525

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223G0001X 4791 NE Primary
General Practice DentistryGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1223G0001X 4488 NE

Addresses

Primary practice location

19103 Mason PLZ
Elkhorn, NE 68022-5659

Mailing address

19103 Mason PLZ
Elkhorn, NE 68022-5659
Phone (402) 933-0525

Other identifiers 1

IdentifierTypeStateIssuer
100251659-00MedicaidNE

National Provider Directory

National Provider Directory

Locations

19103 Mason Plz
Elkhorn, NE 68022
Phone (402) 933-0525

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1298851200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1298851200000",
    "number": "1073811014",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19103 MASON PLZ",
            "city": "ELKHORN",
            "state": "NE",
            "postal_code": "680225659",
            "telephone_number": "402-933-0525",
            "fax_number": "402-933-2925"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19103 MASON PLZ",
            "city": "ELKHORN",
            "state": "NE",
            "postal_code": "680225659",
            "telephone_number": "402-933-0525",
            "fax_number": "402-933-2925"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADOW RIDGE DENTAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-28",
        "last_updated": "2011-02-28",
        "status": "A",
        "authorized_official_last_name": "BECKER",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "402-933-0525",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "NE",
            "license": "4791",
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "NE",
            "license": "4488",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100251659-00",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Elkhorn, NE

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.