Provider Demographics
NPI:1033170857
Name:MAIN STREET FAMILY DENTAL CARE P.A.
Entity Type:Organization
Organization Name:MAIN STREET FAMILY DENTAL CARE P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:GROUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-227-6561
Mailing Address - Street 1:411 MAIN ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1080
Mailing Address - Country:US
Mailing Address - Phone:651-227-6561
Mailing Address - Fax:651-297-6852
Practice Address - Street 1:411 MAIN ST
Practice Address - Street 2:SUITE 308
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1080
Practice Address - Country:US
Practice Address - Phone:651-227-6561
Practice Address - Fax:651-297-6852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN90681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty