Provider Demographics
NPI:1730351214
Name:MENDOTA HEIGHTS DENTAL CENTER
Entity type:Organization
Organization Name:MENDOTA HEIGHTS DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAXA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-455-4223
Mailing Address - Street 1:880 SIBLEY MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1736
Mailing Address - Country:US
Mailing Address - Phone:651-455-4223
Mailing Address - Fax:651-455-0107
Practice Address - Street 1:880 SIBLEY MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55118-1736
Practice Address - Country:US
Practice Address - Phone:651-455-4223
Practice Address - Fax:651-455-0107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9102261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental