Provider Demographics
NPI:1205944923
Name:MACK, DAVID RAY
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAY
Last Name:MACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11536 S 31ST ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-5529
Mailing Address - Country:US
Mailing Address - Phone:402-291-4468
Mailing Address - Fax:402-933-2014
Practice Address - Street 1:11536 S 31ST ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-5529
Practice Address - Country:US
Practice Address - Phone:402-291-4468
Practice Address - Fax:402-933-2014
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE63751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025213600Medicaid