Provider Demographics
NPI:1225786411
Name:PL DENTAL SC
Entity Type:Organization
Organization Name:PL DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:VINH
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-317-1168
Mailing Address - Street 1:9920 FOLEY BLVD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5216
Mailing Address - Country:US
Mailing Address - Phone:633-171-1667
Mailing Address - Fax:763-317-1167
Practice Address - Street 1:9920 FOLEY BLVD NW STE 110
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5216
Practice Address - Country:US
Practice Address - Phone:763-317-1166
Practice Address - Fax:763-317-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-16
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1790131791Medicaid