# MPDA BROKEN BOW LLC

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

## Provider details

- **NPI number:** 1376294298
- **Authorized official:** BENJAMIN ALLEN LASHLEY DDS (SOLE MEMBER)
- **Authorized official phone:** (308) 534-1289

## Contact information

- **Practice address:** 2021 SOUTH E, SUITE 5, BROKEN BOW, NE 68822
- **Practice address phone:** (308) 767-2004
- **Practice address fax:** (308) 767-2006
- **Mailing address:** 2021 SOUTH E, SUITE 5, BROKEN BOW, NE 68822
- **Mailing address phone:** (308) 767-2004
- **Mailing address fax:** (308) 767-2006

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | — | Yes |
| 1223G0001X | General Practice Dentistry | — | — | — |

## Other

- **Enumeration date:** 01/12/2022
- **Last updated:** 01/12/2022