Provider Demographics
NPI:1053690198
Name:RIVERDALE PEDIATRIC DENTISTRY P.A.
Entity Type:Organization
Organization Name:RIVERDALE PEDIATRIC DENTISTRY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:RINDELAUB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-767-1524
Mailing Address - Street 1:3585 124TH AVE NW
Mailing Address - Street 2:STE 400
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-1006
Mailing Address - Country:US
Mailing Address - Phone:763-767-1524
Mailing Address - Fax:763-767-1528
Practice Address - Street 1:3585 124TH AVE NW
Practice Address - Street 2:STE 400
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-1006
Practice Address - Country:US
Practice Address - Phone:763-767-1524
Practice Address - Fax:763-767-1528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty