Provider Demographics
NPI:1417070509
Name:IMMANUEL DENTAL
Entity Type:Organization
Organization Name:IMMANUEL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:DUNGY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-463-2880
Mailing Address - Street 1:321 THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024
Mailing Address - Country:US
Mailing Address - Phone:651-463-2880
Mailing Address - Fax:651-463-2840
Practice Address - Street 1:321 THIRD STREET
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024
Practice Address - Country:US
Practice Address - Phone:651-463-2880
Practice Address - Fax:651-463-2840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10129122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty