Provider Demographics
NPI:1093882656
Name:THE SALVATION ARMY
Entity Type:Organization
Organization Name:THE SALVATION ARMY
Other - Org Name:THE SALVATION ARMY GOOD SAMARITAN DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GOVERNMENT GRANTWRITER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:UTHKE-SCALETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DELEGATED OFFICIAL
Authorized Official - Phone:651-746-3543
Mailing Address - Street 1:20 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-3706
Mailing Address - Country:US
Mailing Address - Phone:507-529-4100
Mailing Address - Fax:507-529-4101
Practice Address - Street 1:120 N BROADWAY STE B
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-3728
Practice Address - Country:US
Practice Address - Phone:507-529-4100
Practice Address - Fax:507-529-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8679100001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN867910000OtherPROVIDER IDENTIFICATION #