Provider Demographics
NPI:1235176033
Name:VATNSDAL, LORRIS GALEN II
Entity Type:Individual
Prefix:DR
First Name:LORRIS
Middle Name:GALEN
Last Name:VATNSDAL
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-0188
Mailing Address - Country:US
Mailing Address - Phone:218-463-2100
Mailing Address - Fax:218-463-3055
Practice Address - Street 1:205A 2ND AVE NW
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1007
Practice Address - Country:US
Practice Address - Phone:218-463-2100
Practice Address - Fax:218-463-3055
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice