Provider Demographics
NPI:1316035595
Name:BRUCE K.A. DORMANEN, P.A.
Entity Type:Organization
Organization Name:BRUCE K.A. DORMANEN, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:KA
Authorized Official - Last Name:DORMANEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-421-9292
Mailing Address - Street 1:2150 3RD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2200
Mailing Address - Country:US
Mailing Address - Phone:763-421-9292
Mailing Address - Fax:763-421-7559
Practice Address - Street 1:2150 3RD AVE STE 200
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2200
Practice Address - Country:US
Practice Address - Phone:763-421-9292
Practice Address - Fax:763-421-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN81511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty