1265853139 NPI number — WINSTED DENTAL PLLC

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 1265853139 NPI number — WINSTED DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINSTED DENTAL PLLC
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:
1265853139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27392 734TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DASSEL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55325-3258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 FAIRLAWN AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTED
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55395-7837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-485-3881
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NESS
Authorized Official First Name:
KENNTH
Authorized Official Middle Name:
DUANE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
320-275-2520

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D9676 , 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)