Provider Demographics
NPI:1225104458
Name:OAK RIDGE DENTAL, LLC
Entity Type:Organization
Organization Name:OAK RIDGE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-435-0355
Mailing Address - Street 1:625 E NICOLLET BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6734
Mailing Address - Country:US
Mailing Address - Phone:952-435-0355
Mailing Address - Fax:952-435-0390
Practice Address - Street 1:625 E NICOLLET BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6734
Practice Address - Country:US
Practice Address - Phone:952-435-0355
Practice Address - Fax:952-435-0390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty