Provider Demographics
NPI:1093044869
Name:HEALTHY TEETH CLUB
Entity Type:Organization
Organization Name:HEALTHY TEETH CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL HYGIENIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:FAHNING
Authorized Official - Suffix:
Authorized Official - Credentials:RDH,BS
Authorized Official - Phone:651-894-4391
Mailing Address - Street 1:13410 CANALVILLE LANE
Mailing Address - Street 2:
Mailing Address - City:GRASSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55030-2162
Mailing Address - Country:US
Mailing Address - Phone:651-894-4391
Mailing Address - Fax:
Practice Address - Street 1:13410 CANALVILLE LANE
Practice Address - Street 2:
Practice Address - City:GRASSTON
Practice Address - State:MN
Practice Address - Zip Code:55030-2162
Practice Address - Country:US
Practice Address - Phone:651-894-4391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty