Provider Demographics
NPI:1194215616
Name:FOUR SEASONS DENTAL PA
Entity Type:Organization
Organization Name:FOUR SEASONS DENTAL PA
Other - Org Name:FOUR SEASONS DENTAL PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KERSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-475-0225
Mailing Address - Street 1:109 BUSHAWAY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2079
Mailing Address - Country:US
Mailing Address - Phone:952-475-0225
Mailing Address - Fax:
Practice Address - Street 1:4205 LANCASTER LN N STE 101
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-1702
Practice Address - Country:US
Practice Address - Phone:763-559-2976
Practice Address - Fax:763-559-4852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental