Provider Demographics
NPI:1003886383
Name:COMMUNITY DENTAL CARE INC
Entity type:Organization
Organization Name:COMMUNITY DENTAL CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HR DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KORI
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-925-8427
Mailing Address - Street 1:1670 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109
Mailing Address - Country:US
Mailing Address - Phone:651-925-8400
Mailing Address - Fax:651-925-8439
Practice Address - Street 1:600 CARLTON STREET N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55119
Practice Address - Country:US
Practice Address - Phone:651-774-2959
Practice Address - Fax:651-774-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
MN460668000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN460668000Medicaid
MNC04113Medicare ID - Type Unspecified