Provider Demographics
NPI:1225112022
Name:LINDSTROM FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:LINDSTROM FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HURSY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-257-4471
Mailing Address - Street 1:PO BOX 705
Mailing Address - Street 2:30554 PARK STREET NORTH
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045
Mailing Address - Country:US
Mailing Address - Phone:651-257-4471
Mailing Address - Fax:651-257-2017
Practice Address - Street 1:30554 PARK STREET NORTH
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045
Practice Address - Country:US
Practice Address - Phone:651-257-4471
Practice Address - Fax:651-257-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN80211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty