1285030387 NPI number — FALLS COURT DENTISTS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285030387 NPI number — FALLS COURT DENTISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FALLS COURT DENTISTS
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:
1285030387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAUK CENTRE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-352-2822
Provider Business Mailing Address Fax Number:
320-351-4577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAUK CENTRE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-352-2822
Provider Business Practice Location Address Fax Number:
320-351-4577
Provider Enumeration Date:
11/17/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HINES
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OFFICE MGR
Authorized Official Telephone Number:
320-632-6621

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  9733 , 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)