Provider Demographics
NPI:1144490723
Name:EAST VALLEYDENTAL, PA
Entity type:Organization
Organization Name:EAST VALLEYDENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:THIELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-423-4414
Mailing Address - Street 1:14050 PILOT KNOB RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6647
Mailing Address - Country:US
Mailing Address - Phone:952-423-4414
Mailing Address - Fax:952-423-7174
Practice Address - Street 1:14050 PILOT KNOB RD
Practice Address - Street 2:SUITE 108
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6647
Practice Address - Country:US
Practice Address - Phone:952-423-4414
Practice Address - Fax:952-423-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND8510261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental