Provider Demographics
NPI:1548708225
Name:VALLEY RIDGE DENTAL ARTS
Entity type:Organization
Organization Name:VALLEY RIDGE DENTAL ARTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-439-0322
Mailing Address - Street 1:12425 55TH ST N STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-7404
Mailing Address - Country:US
Mailing Address - Phone:651-439-0322
Mailing Address - Fax:
Practice Address - Street 1:12425 55TH ST N STE B
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-7404
Practice Address - Country:US
Practice Address - Phone:651-439-0322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12824305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization