1508962994 NPI number — HEALTH SOURCE DENTAL CLINIC

Table of content: (NPI 1508962994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508962994 NPI number — HEALTH SOURCE DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH SOURCE DENTAL CLINIC
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:
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:
1508962994
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 LABORE RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
VADNAIS HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-5186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-539-7200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 BIRCH ST. N
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-347-4399
Provider Business Practice Location Address Fax Number:
651-431-7641
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLANCEY
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
651-539-7200

Provider Taxonomy Codes

  • Taxonomy code: 1223D0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 366053200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com