Provider Demographics
NPI:1871106393
Name:FOREST LAKE ENDODONTICS
Entity type:Organization
Organization Name:FOREST LAKE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:KLOSSNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-464-9888
Mailing Address - Street 1:1420 LAKE ST S STE 200
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2713
Mailing Address - Country:US
Mailing Address - Phone:651-464-9888
Mailing Address - Fax:
Practice Address - Street 1:1420 LAKE ST S STE 200
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2713
Practice Address - Country:US
Practice Address - Phone:651-464-9888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-25
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty