# SHADOW RIDGE DENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1073811014
- **Authorized official:** JAMES W BECKER DDS (OWNER)
- **Authorized official phone:** (402) 933-0525

## Contact information

- **Practice address:** 19103 MASON PLZ, ELKHORN, NE 68022-5659
- **Practice address phone:** (402) 933-0525
- **Practice address fax:** (402) 933-2925
- **Mailing address:** 19103 MASON PLZ, ELKHORN, NE 68022-5659
- **Mailing address phone:** (402) 933-0525
- **Mailing address fax:** (402) 933-2925

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 4488 | NE | — |
| 1223G0001X | General Practice Dentistry | 4791 | NE | Yes |

## Other

- **Enumeration date:** 02/28/2011
- **Last updated:** 02/28/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100251659-00 | — | NE |