Provider Demographics
NPI:1861579658
Name:RIVERSIDE DENTAL CARE,LLC
Entity type:Organization
Organization Name:RIVERSIDE DENTAL CARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-931-5646
Mailing Address - Street 1:217 NASSAU ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-2055
Mailing Address - Country:US
Mailing Address - Phone:507-931-5646
Mailing Address - Fax:507-934-0148
Practice Address - Street 1:217 NASSAU ST
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-2055
Practice Address - Country:US
Practice Address - Phone:507-931-5646
Practice Address - Fax:507-934-0148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNJ33063DAHOtherBCBS MEDICAL ID NUMBER