Provider Demographics
NPI:1285032243
Name:MAIN STREET DENTAL CLINIC OF MANKATO, PLLP
Entity Type:Organization
Organization Name:MAIN STREET DENTAL CLINIC OF MANKATO, PLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-583-2141
Mailing Address - Street 1:287 ST ANDREWS DRIVE
Mailing Address - Street 2:100
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-8584
Mailing Address - Country:US
Mailing Address - Phone:507-720-0250
Mailing Address - Fax:
Practice Address - Street 1:287 ST ANDREWS DRIVE
Practice Address - Street 2:100
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-720-0250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty