Provider Demographics
NPI:1053831941
Name:CHANHASSEN FAMILY DENTISTRY PA
Entity Type:Organization
Organization Name:CHANHASSEN FAMILY DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-443-3368
Mailing Address - Street 1:8116 MALLORY CT
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-8586
Mailing Address - Country:US
Mailing Address - Phone:953-443-3368
Mailing Address - Fax:952-443-3330
Practice Address - Street 1:8116 MALLORY CT
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-8586
Practice Address - Country:US
Practice Address - Phone:953-443-3368
Practice Address - Fax:952-443-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty