Provider Demographics
NPI:1346410909
Name:CENTER STREET DENTAL PROFESSIONALS, P.A.
Entity Type:Organization
Organization Name:CENTER STREET DENTAL PROFESSIONALS, P.A.
Other - Org Name:NGHI TRINH-PHAM, DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NGHI
Authorized Official - Middle Name:
Authorized Official - Last Name:TRINH-PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-463-1070
Mailing Address - Street 1:308 CENTER ST W
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-1419
Mailing Address - Country:US
Mailing Address - Phone:218-463-1070
Mailing Address - Fax:218-463-1170
Practice Address - Street 1:308 CENTER ST W
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1419
Practice Address - Country:US
Practice Address - Phone:218-463-1070
Practice Address - Fax:218-463-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8357122300000X
1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1346410909OtherFEE FOR SERVICE PROVIDER