Provider Demographics
NPI:1285030387
Name:FALLS COURT DENTISTS
Entity Type:Organization
Organization Name:FALLS COURT DENTISTS
Other - Org Name:MAIN STREET DENTAL OF SAUK CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-632-6621
Mailing Address - Street 1:304 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAUK CENTRE
Mailing Address - State:MN
Mailing Address - Zip Code:56378
Mailing Address - Country:US
Mailing Address - Phone:320-352-2822
Mailing Address - Fax:320-351-4577
Practice Address - Street 1:304 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAUK CENTRE
Practice Address - State:MN
Practice Address - Zip Code:56378
Practice Address - Country:US
Practice Address - Phone:320-352-2822
Practice Address - Fax:320-351-4577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FALLS COURT DENTISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-17
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN97331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty