1841462652 NPI number — MAHTOMEDI DENTAL CLINIC

Table of content: (NPI 1841462652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841462652 NPI number — MAHTOMEDI DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAHTOMEDI 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:
NORTH ST. PAUL DENTAL
Provider Other Organization Name Type Code:
5
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:
1841462652
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
814 MAHTOMEDI AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAHTOMEDI
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55115-1730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-426-0011
Provider Business Mailing Address Fax Number:
651-426-2075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
814 MAHTOMEDI AVE
Provider Second Line Business Practice Location Address:
MAHTOMEDI DENTAL
Provider Business Practice Location Address City Name:
MAHTOMEDI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55115-1730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-426-0011
Provider Business Practice Location Address Fax Number:
651-426-2075
Provider Enumeration Date:
04/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BRAY
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER - DENTIST
Authorized Official Telephone Number:
651-426-0011

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D8217 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 11396 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 982017500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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