Provider Demographics
NPI:1003886383
Name:COMMUNITY DENTAL CARE INC
Entity Type:Organization
Organization Name:COMMUNITY DENTAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VACHAREE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-925-8400
Mailing Address - Street 1:1670 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109
Mailing Address - Country:US
Mailing Address - Phone:651-925-8400
Mailing Address - Fax:651-925-8439
Practice Address - Street 1:828 HAWTHORNE AVE E
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106
Practice Address - Country:US
Practice Address - Phone:651-774-2959
Practice Address - Fax:651-774-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN460668000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN460668000Medicaid
MNC04113Medicare ID - Type Unspecified