Provider Demographics
NPI:1265845937
Name:PINE RIVER DENTAL CENTER LLC
Entity Type:Organization
Organization Name:PINE RIVER DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:PREBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-587-4438
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:PINE RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56474-0650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 PARK AVE W
Practice Address - Street 2:
Practice Address - City:PINE RIVER
Practice Address - State:MN
Practice Address - Zip Code:56474-4495
Practice Address - Country:US
Practice Address - Phone:218-587-4438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND133931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty