Provider Demographics
NPI:1043715204
Name:MINNESOTA DENTAL PROFESSIONALS, P.C.
Entity type:Organization
Organization Name:MINNESOTA DENTAL PROFESSIONALS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8426
Mailing Address - Street 1:16138 PILOT KNOB RD
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4105
Mailing Address - Country:US
Mailing Address - Phone:952-679-7779
Mailing Address - Fax:952-679-7778
Practice Address - Street 1:16138 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044
Practice Address - Country:US
Practice Address - Phone:952-679-7779
Practice Address - Fax:952-679-7778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-28
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty