Provider Demographics
NPI:1336656768
Name:RIDGES DENTAL
Entity Type:Organization
Organization Name:RIDGES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTELSTEADT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-681-9044
Mailing Address - Street 1:625 E NICOLLET BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6735
Mailing Address - Country:US
Mailing Address - Phone:952-435-0300
Mailing Address - Fax:952-435-0360
Practice Address - Street 1:625 E NICOLLET BLVD STE 202
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6735
Practice Address - Country:US
Practice Address - Phone:952-435-0300
Practice Address - Fax:952-435-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental