Provider Demographics
NPI:1083853113
Name:BIRCH LAKE DENTAL PA
Entity Type:Organization
Organization Name:BIRCH LAKE DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEETHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAMODARAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-429-0404
Mailing Address - Street 1:2641 WHITE BEAR PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110
Mailing Address - Country:US
Mailing Address - Phone:651-429-0404
Mailing Address - Fax:651-429-0472
Practice Address - Street 1:2641 WHITE BEAR PARKWAY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-429-0404
Practice Address - Fax:651-429-0472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10949MN1223G0001X
MN7712MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty