1003886383 NPI number — COMMUNITY DENTAL CARE INC

Table of content: (NPI 1003886383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003886383 NPI number — COMMUNITY DENTAL CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY DENTAL CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003886383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1670 BEAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLEWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-925-8400
Provider Business Mailing Address Fax Number:
651-925-8439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 CARLTON STREET N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-774-2959
Provider Business Practice Location Address Fax Number:
651-774-1997
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
KORI
Authorized Official Middle Name:
C
Authorized Official Title or Position:
HR DIRECTOR
Authorized Official Telephone Number:
651-925-8427

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 460668000 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 460668000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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