Provider Demographics
NPI:1417340563
Name:MIRACLE MILE DENTISTRY PA
Entity Type:Organization
Organization Name:MIRACLE MILE DENTISTRY PA
Other - Org Name:36TH STREET DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DUNLAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-799-7525
Mailing Address - Street 1:5806A W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5108
Mailing Address - Country:US
Mailing Address - Phone:952-929-5292
Mailing Address - Fax:
Practice Address - Street 1:5806A W 36TH ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5108
Practice Address - Country:US
Practice Address - Phone:952-929-5292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty