1710215793 NPI number — SHETEK DENTAL CARE PA

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 1710215793 NPI number — SHETEK DENTAL CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHETEK DENTAL CARE PA
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:
6
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:
1710215793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2711 BROADWAY AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SLAYTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56172-1313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-836-1000
Provider Business Mailing Address Fax Number:
507-836-1008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2711 BROADWAY AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SLAYTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56172-1313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-836-1000
Provider Business Practice Location Address Fax Number:
507-836-1008
Provider Enumeration Date:
12/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HULSTEIN
Authorized Official First Name:
NARLA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
507-836-1000

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D12229 , 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)





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