Provider Demographics
NPI:1225204704
Name:NORTH COUNTRY DENTAL SERVICE
Entity Type:Organization
Organization Name:NORTH COUNTRY DENTAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUETH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-751-1111
Mailing Address - Street 1:1311 BEMIDJI AVE N
Mailing Address - Street 2:P.O. BOX 1310
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3811
Mailing Address - Country:US
Mailing Address - Phone:218-751-1111
Mailing Address - Fax:
Practice Address - Street 1:1311 BEMIDJI AVE N
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3811
Practice Address - Country:US
Practice Address - Phone:218-751-1111
Practice Address - Fax:218-444-6318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN843220100Medicaid