Provider Demographics
NPI:1073674529
Name:DOWNTOWN DENTAL CARE PA
Entity Type:Organization
Organization Name:DOWNTOWN DENTAL CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:STODOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-485-4455
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:304 ELM AVE
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767
Mailing Address - Country:US
Mailing Address - Phone:218-485-4455
Mailing Address - Fax:218-485-0227
Practice Address - Street 1:304 ELM AVE
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767
Practice Address - Country:US
Practice Address - Phone:218-485-4455
Practice Address - Fax:218-485-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty