1538112180 NPI number — CHANHASSEN DENTAL

Table of content: (NPI 1538112180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538112180 NPI number — CHANHASSEN DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANHASSEN DENTAL
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:
1538112180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANHASSEN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55317-0189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-934-3383
Provider Business Mailing Address Fax Number:
952-934-6668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 W 78TH ST
Provider Second Line Business Practice Location Address:
SUITE #116
Provider Business Practice Location Address City Name:
CHANHASSEN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55317-4527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-934-3383
Provider Business Practice Location Address Fax Number:
952-934-6668
Provider Enumeration Date:
05/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
JOLEEN
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
952-934-3383

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  7951 , 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: 10519 , 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)