Provider Demographics
NPI:1407224827
Name:CHILDREN'S DENTAL SERVICES
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WOVCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-746-1530
Mailing Address - Street 1:325 N SIBLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-2150
Mailing Address - Country:US
Mailing Address - Phone:612-746-1530
Mailing Address - Fax:612-746-1531
Practice Address - Street 1:325 N SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-2150
Practice Address - Country:US
Practice Address - Phone:612-746-1530
Practice Address - Fax:612-746-1531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9212238Medicaid