Provider Demographics
NPI:1164446282
Name:PROFESSIONAL DRIVE DENTAL GROUP P.A.
Entity Type:Organization
Organization Name:PROFESSIONAL DRIVE DENTAL GROUP P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:L
Authorized Official - Last Name:APPELDOORN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-645-5264
Mailing Address - Street 1:600 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-2755
Mailing Address - Country:US
Mailing Address - Phone:507-645-5264
Mailing Address - Fax:507-663-0303
Practice Address - Street 1:600 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-2755
Practice Address - Country:US
Practice Address - Phone:507-645-5264
Practice Address - Fax:507-663-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty