Provider Demographics
NPI:1073997029
Name:APOLLO DENTAL CENTER
Entity Type:Organization
Organization Name:APOLLO DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:BERSCHEID BRUNN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-287-8320
Mailing Address - Street 1:3000 43RD ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-5847
Mailing Address - Country:US
Mailing Address - Phone:507-287-8320
Mailing Address - Fax:507-281-8757
Practice Address - Street 1:3000 43RD ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-5847
Practice Address - Country:US
Practice Address - Phone:507-287-8320
Practice Address - Fax:507-281-8757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13598122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND13598OtherMINNESOTA BOARD OF DENTISTRY LICENSE NUMBER