Provider Demographics
NPI:1073953832
Name:EAGAN VALLEY DENTAL CENTER
Entity Type:Organization
Organization Name:EAGAN VALLEY DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MITTELSTEADT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-423-4414
Mailing Address - Street 1:14050 PILOT KNOB RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6647
Mailing Address - Country:US
Mailing Address - Phone:952-423-4414
Mailing Address - Fax:
Practice Address - Street 1:14050 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-6647
Practice Address - Country:US
Practice Address - Phone:952-423-4414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty