Provider Demographics
NPI:1306009667
Name:ALTERNATIVE DENTAL NETWORK
Entity Type:Organization
Organization Name:ALTERNATIVE DENTAL NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-280-0350
Mailing Address - Street 1:8014 HIGHWAY 55
Mailing Address - Street 2:# 154
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4712
Mailing Address - Country:US
Mailing Address - Phone:612-280-0350
Mailing Address - Fax:
Practice Address - Street 1:8014 HWY 55
Practice Address - Street 2:STE 154
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427
Practice Address - Country:US
Practice Address - Phone:612-280-0350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization