Provider Demographics
NPI:1275969263
Name:MAHTOMEDI DENTAL P.C.
Entity Type:Organization
Organization Name:MAHTOMEDI DENTAL P.C.
Other - Org Name:GRACE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STODOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-430-1020
Mailing Address - Street 1:12425 55TH ST N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-7403
Mailing Address - Country:US
Mailing Address - Phone:651-430-1020
Mailing Address - Fax:651-439-2201
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:651-430-1020
Practice Address - Fax:651-439-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11396122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty