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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 820436 | 01 | MN | UNITED CONCORDIA | OTHER | 7B014FO | 01 | MN | BCBS MN | OTHER |