Provider Demographics
NPI:1376814939
Name:BLACKDUCK DENTAL CLINIC PSC
Entity Type:Organization
Organization Name:BLACKDUCK DENTAL CLINIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-835-4227
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:BLACKDUCK
Mailing Address - State:MN
Mailing Address - Zip Code:56630-0308
Mailing Address - Country:US
Mailing Address - Phone:218-835-4227
Mailing Address - Fax:
Practice Address - Street 1:49 SUMMIT AVE. E.
Practice Address - Street 2:
Practice Address - City:BLACKDUCK
Practice Address - State:MN
Practice Address - Zip Code:56630-9727
Practice Address - Country:US
Practice Address - Phone:218-835-4227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty