Provider Demographics
NPI:1245389246
Name:METROPOLITAN PEDIATRIC DENTAL ASSOCIATES, LTD
Entity Type:Organization
Organization Name:METROPOLITAN PEDIATRIC DENTAL ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:NICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-224-4969
Mailing Address - Street 1:1021 BANDANA BLVD E
Mailing Address - Street 2:SUITE 121
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5113
Mailing Address - Country:US
Mailing Address - Phone:651-224-4969
Mailing Address - Fax:651-223-8047
Practice Address - Street 1:1021 BANDANA BLVD E
Practice Address - Street 2:SUITE 121
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5113
Practice Address - Country:US
Practice Address - Phone:651-224-4969
Practice Address - Fax:651-223-8047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:METROPOLITAN PEDIATRIC DENTAL ASSOCIATES, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-09
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN518322700Medicaid