1003009374 NPI number — ENDODONTIC PROFESSIONALS PA ARBOR LAKES ENDODONTICS

Table of content: DR. HEIDI KOLLER VAN HORNE PSY.D, (NPI 1427273556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003009374 NPI number — ENDODONTIC PROFESSIONALS PA ARBOR LAKES ENDODONTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENDODONTIC PROFESSIONALS PA ARBOR LAKES ENDODONTICS
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:
1003009374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12000 ELM CREEK BLVD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-416-3619
Provider Business Mailing Address Fax Number:
763-416-3695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12000 ELM CREEK BLVD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-416-3619
Provider Business Practice Location Address Fax Number:
763-416-3695
Provider Enumeration Date:
08/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KARN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
763-416-3619

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  6500003 , 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)





Copyright © 2007-2025 www.npivalidator.com