Provider Demographics
NPI:1134300098
Name:PERHAM FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PERHAM FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:STURDEVANT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-346-7186
Mailing Address - Street 1:918 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-2118
Mailing Address - Country:US
Mailing Address - Phone:218-346-7186
Mailing Address - Fax:
Practice Address - Street 1:918 MARKET ST
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2118
Practice Address - Country:US
Practice Address - Phone:218-346-7186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12405261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental