Provider Demographics
NPI:1144484205
Name:DISTINCTIVE DENTAL SERVICES PA
Entity type:Organization
Organization Name:DISTINCTIVE DENTAL SERVICES PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:THOENNES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-572-9762
Mailing Address - Street 1:4716 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:HILLTOP
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1944
Mailing Address - Country:US
Mailing Address - Phone:763-572-9762
Mailing Address - Fax:763-572-2827
Practice Address - Street 1:4716 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:HILLTOP
Practice Address - State:MN
Practice Address - Zip Code:55421-1944
Practice Address - Country:US
Practice Address - Phone:763-572-9762
Practice Address - Fax:763-572-2827
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISTINCTIVE DENTAL SERVICES, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND089711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN949522300Medicaid