Provider Demographics
NPI:1003278870
Name:HANCOCK DENTAL CLINIC, PA
Entity Type:Organization
Organization Name:HANCOCK DENTAL CLINIC, PA
Other - Org Name:HANCOCK AND CHOKIO DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-392-5300
Mailing Address - Street 1:657 ATLANTIC AVE
Mailing Address - Street 2:PO BOX 395
Mailing Address - City:HANCOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56244-2104
Mailing Address - Country:US
Mailing Address - Phone:320-392-5300
Mailing Address - Fax:320-392-5302
Practice Address - Street 1:657 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MN
Practice Address - Zip Code:56244-2104
Practice Address - Country:US
Practice Address - Phone:320-392-5300
Practice Address - Fax:320-392-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10212261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1306931720OtherNPI