Provider Demographics
NPI:1225696925
Name:MINNESOTA DENTAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:MINNESOTA DENTAL PROFESSIONALS, P.C.
Other - Org Name:DENTAL CARE OF BROOKLYN PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:5901 94TH AVE N STE 105
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2389
Mailing Address - Country:US
Mailing Address - Phone:763-717-0020
Mailing Address - Fax:763-432-0821
Practice Address - Street 1:5901 94TH AVE N STE 105
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-2389
Practice Address - Country:US
Practice Address - Phone:763-703-2512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-29
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty