Provider Demographics
NPI:1265644926
Name:VALLEY RIDGE DENTAL, LLC
Entity Type:Organization
Organization Name:VALLEY RIDGE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-766-5771
Mailing Address - Street 1:4666 DALE ST N
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-6021
Mailing Address - Country:US
Mailing Address - Phone:651-766-5771
Mailing Address - Fax:
Practice Address - Street 1:12425 55TH ST N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-7403
Practice Address - Country:US
Practice Address - Phone:651-439-0322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty