Provider Demographics
NPI:1902146335
Name:EAGAN VALLEY DENTAL CENTER P.A.
Entity Type:Organization
Organization Name:EAGAN VALLEY DENTAL CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MITTELSTEADT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-681-9044
Mailing Address - Street 1:4555 ERIN DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3398
Mailing Address - Country:US
Mailing Address - Phone:651-681-9044
Mailing Address - Fax:651-681-0599
Practice Address - Street 1:4555 ERIN DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3398
Practice Address - Country:US
Practice Address - Phone:651-681-9044
Practice Address - Fax:651-681-0599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN09922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty