Basic Information
| Provider Information | |||||||||
| NPI: | 1669842662 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S DENTAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 636 BROADWAY ST NE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554132164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127461530 | ||||||||
| FaxNumber: | 6127461531 | ||||||||
| Practice Location | |||||||||
| Address1: | 229 W LAKE ST | ||||||||
| Address2: | |||||||||
| City: | CHISHOLM | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127461530 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2015 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | WOVCHA | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6127461530 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health |
No ID Information.