Provider Demographics
NPI:1376648402
Name:PENN AVENUE FAMILY DENTAL
Entity Type:Organization
Organization Name:PENN AVENUE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCNAB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-922-0894
Mailing Address - Street 1:5346 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1065
Mailing Address - Country:US
Mailing Address - Phone:612-922-0894
Mailing Address - Fax:612-922-1352
Practice Address - Street 1:5346 PENN AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1065
Practice Address - Country:US
Practice Address - Phone:612-922-0894
Practice Address - Fax:612-922-1352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN92201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty