1932247921 NPI number — SOUTHERN HEIGHTS DENTAL GROUP PA

Table of content: (NPI 1932247921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932247921 NPI number — SOUTHERN HEIGHTS DENTAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN HEIGHTS DENTAL GROUP 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:
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:
1932247921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1575 20TH STREET NORTHWEST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
FARIBAULT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-334-6433
Provider Business Mailing Address Fax Number:
507-334-0044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1575 20TH STREET NORTHWEST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FARIBAULT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-334-6433
Provider Business Practice Location Address Fax Number:
507-334-0044
Provider Enumeration Date:
02/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TONJUM
Authorized Official First Name:
KATE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
507-334-6433

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D7800 , 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: D9884 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D10323 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D11586 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D11400 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D11631 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D8742 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD0000X , with the licence number: D7800 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD0000X , with the licence number: D13095 , 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: 550722700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 607320400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 148427300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 284735300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 856415900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 325522100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 440217100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 443655000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 849698600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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