Provider Demographics
NPI:1285022145
Name:DENTAL DEPOT, LLC
Entity Type:Organization
Organization Name:DENTAL DEPOT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-589-4481
Mailing Address - Street 1:2 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1344
Mailing Address - Country:US
Mailing Address - Phone:320-589-4481
Mailing Address - Fax:
Practice Address - Street 1:2 E 5TH ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1344
Practice Address - Country:US
Practice Address - Phone:320-589-4481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13075122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty