Provider Demographics
NPI:1861708828
Name:GREAT RIVER ENDODONTICS, PA
Entity type:Organization
Organization Name:GREAT RIVER ENDODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KARN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:320-259-5078
Mailing Address - Street 1:622 ROOSEVELT RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-6153
Mailing Address - Country:US
Mailing Address - Phone:320-259-5078
Mailing Address - Fax:320-259-1484
Practice Address - Street 1:622 ROOSEVELT RD
Practice Address - Street 2:SUITE 180
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6153
Practice Address - Country:US
Practice Address - Phone:320-259-5078
Practice Address - Fax:320-259-1484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNUNKNOWN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty