Provider Demographics
NPI:1730256132
Name:ANDOVER FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:ANDOVER FAMILY DENTISTRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHUTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-427-4780
Mailing Address - Street 1:3480 BUNKER LAKE BLVD NW
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304
Mailing Address - Country:US
Mailing Address - Phone:763-427-4780
Mailing Address - Fax:763-427-8471
Practice Address - Street 1:3480 BUNKER LAKE BLVD NW
Practice Address - Street 2:SUITE 202
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304
Practice Address - Country:US
Practice Address - Phone:763-427-4780
Practice Address - Fax:763-427-8471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114391223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty