Basic Information
Provider Information
NPI: 1871672584
EntityType: 2
ReplacementNPI:  
OrganizationName: LAKE SUPERIOR DENTAL ASSOCIATES
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1225 E 1ST ST
Address2:  
City: DULUTH
State: MN
PostalCode: 558052402
CountryCode: US
TelephoneNumber: 2187286445
FaxNumber: 2187247003
Practice Location
Address1: 1225 E 1ST ST
Address2:  
City: DULUTH
State: MN
PostalCode: 558052402
CountryCode: US
TelephoneNumber: 2187286445
FaxNumber: 2187247003
Other Information
ProviderEnumerationDate: 11/03/2006
LastUpdateDate: 10/30/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: RYAN
AuthorizedOfficialFirstName: ROBERT
AuthorizedOfficialMiddleName: G
AuthorizedOfficialTitleorPosition: PARTNER
AuthorizedOfficialTelephone: 2187286445
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: DDS
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X  Y193400000X SINGLE SPECIALTY GROUPDental ProvidersDentistGeneral Practice

ID Information
IDTypeStateIssuerDescription
82043601MNUNITED CONCORDIAOTHER
7B014FO01MNBCBS MNOTHER


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