Provider Demographics
NPI:1114130010
Name:NORTHWEST FAMILY DENTAL CENTER TN
Entity Type:Organization
Organization Name:NORTHWEST FAMILY DENTAL CENTER TN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:DESIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-497-2367
Mailing Address - Street 1:12725 43RD ST NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4900
Mailing Address - Country:US
Mailing Address - Phone:763-497-2367
Mailing Address - Fax:763-497-8171
Practice Address - Street 1:12725 43RD ST NE
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-4900
Practice Address - Country:US
Practice Address - Phone:763-497-2367
Practice Address - Fax:763-497-8171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN84241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty