Provider Demographics
NPI:1205204674
Name:WILLMAR FAMILY DENTISTRY, P.A.
Entity Type:Organization
Organization Name:WILLMAR FAMILY DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-235-2010
Mailing Address - Street 1:1016 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3510
Mailing Address - Country:US
Mailing Address - Phone:320-235-2010
Mailing Address - Fax:320-235-7133
Practice Address - Street 1:1016 1ST ST S
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3510
Practice Address - Country:US
Practice Address - Phone:320-235-2010
Practice Address - Fax:320-235-7133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9800122300000X
MNDT54125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No125J00000XDental ProvidersDental TherapistGroup - Single Specialty