Provider Demographics
NPI:1053834481
Name:MONDALE DENTAL
Entity Type:Organization
Organization Name:MONDALE DENTAL
Other - Org Name:ROGER MONDALE, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-512-8500
Mailing Address - Street 1:10600 OLD COUNTY ROAD 15 STE 120
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6205
Mailing Address - Country:US
Mailing Address - Phone:763-512-8501
Mailing Address - Fax:763-512-8592
Practice Address - Street 1:10600 OLD COUNTY ROAD 15 STE 120
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6205
Practice Address - Country:US
Practice Address - Phone:763-512-8501
Practice Address - Fax:763-512-8592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental