Provider Demographics
NPI:1902596943
Name:EDEN LAKES DENTAL LLC
Entity Type:Organization
Organization Name:EDEN LAKES DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCESCA
Authorized Official - Middle Name:
Authorized Official - Last Name:CATIBOG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-626-6883
Mailing Address - Street 1:7000 YORKTOWN LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7603
Mailing Address - Country:US
Mailing Address - Phone:818-626-6883
Mailing Address - Fax:
Practice Address - Street 1:9613 ANDERSON LAKES PKWY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-4155
Practice Address - Country:US
Practice Address - Phone:952-941-0470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental