Provider Demographics
NPI:1285032136
Name:DEWEY STREET DENTAL
Entity Type:Organization
Organization Name:DEWEY STREET DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-968-7062
Mailing Address - Street 1:P.O. BOX 649
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56329
Mailing Address - Country:US
Mailing Address - Phone:320-968-7062
Mailing Address - Fax:
Practice Address - Street 1:311 DEWEY ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:MN
Practice Address - Zip Code:56329-8447
Practice Address - Country:US
Practice Address - Phone:320-968-7062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty