Provider Demographics
NPI:1275707580
Name:ADVANCED DENTAL GROUP
Entity Type:Organization
Organization Name:ADVANCED DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:A
Authorized Official - Last Name:HELLICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-789-3573
Mailing Address - Street 1:3909 SILVER LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-4352
Mailing Address - Country:US
Mailing Address - Phone:612-789-3573
Mailing Address - Fax:
Practice Address - Street 1:3909 SILVER LAKE RD NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-4352
Practice Address - Country:US
Practice Address - Phone:612-789-3573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND66701223G0001X
MND79101223G0001X
MND77121223G0001X
MND114081223G0001X
MND106501223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty