Provider Demographics
NPI:1114360492
Name:INSIDE EDGE DENTAL PLLC
Entity Type:Organization
Organization Name:INSIDE EDGE DENTAL PLLC
Other - Org Name:EAST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARKER JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-774-6085
Mailing Address - Street 1:1346 PAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-3434
Mailing Address - Country:US
Mailing Address - Phone:651-774-6085
Mailing Address - Fax:651-774-2660
Practice Address - Street 1:1346 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-3434
Practice Address - Country:US
Practice Address - Phone:651-774-6085
Practice Address - Fax:651-774-2660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty