Provider Demographics
NPI:1225811102
Name:MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE AND OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:218-444-9147
Mailing Address - Street 1:1405 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5113
Mailing Address - Country:US
Mailing Address - Phone:218-444-9147
Mailing Address - Fax:218-444-9252
Practice Address - Street 1:13 MAIN AVE N
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621-8315
Practice Address - Country:US
Practice Address - Phone:218-694-6571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental