Provider Demographics
NPI:1144717299
Name:GREAT ODENS, LLC
Entity type:Organization
Organization Name:GREAT ODENS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-370-3200
Mailing Address - Street 1:241 CLEVELAND AVE S STE D
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1208
Mailing Address - Country:US
Mailing Address - Phone:651-699-3212
Mailing Address - Fax:651-698-8898
Practice Address - Street 1:241 CLEVELAND AVE S STE D
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1208
Practice Address - Country:US
Practice Address - Phone:651-699-3212
Practice Address - Fax:651-698-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-14
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13542122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty