Provider Demographics
NPI:1073780805
Name:DISTINCTIVE DENTAL SERVICES, PA
Entity Type:Organization
Organization Name:DISTINCTIVE DENTAL SERVICES, PA
Other - Org Name:HOWARD LAKE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:THOENNES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-485-4344
Mailing Address - Street 1:612 8TH AVE # 664
Mailing Address - Street 2:
Mailing Address - City:HOWARD LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55349-5137
Mailing Address - Country:US
Mailing Address - Phone:320-543-2233
Mailing Address - Fax:320-543-2368
Practice Address - Street 1:612 8TH AVE # 664
Practice Address - Street 2:
Practice Address - City:HOWARD LAKE
Practice Address - State:MN
Practice Address - Zip Code:55349-5137
Practice Address - Country:US
Practice Address - Phone:320-543-2233
Practice Address - Fax:320-543-2368
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISTINCTIVE DENTAL SERVICES, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND089711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty