Provider Demographics
NPI:1033206750
Name:PINE RIDGE DENTAL PA
Entity Type:Organization
Organization Name:PINE RIDGE DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRESEN NARR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-856-5100
Mailing Address - Street 1:PO BOX 223
Mailing Address - Street 2:26273 2ND ST E SUITE A
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398
Mailing Address - Country:US
Mailing Address - Phone:763-856-5100
Mailing Address - Fax:763-856-0366
Practice Address - Street 1:26273 2ND ST E
Practice Address - Street 2:SUITE A
Practice Address - City:ZIMMERMAN
Practice Address - State:MN
Practice Address - Zip Code:55398
Practice Address - Country:US
Practice Address - Phone:763-856-5100
Practice Address - Fax:763-856-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty