Provider Demographics
NPI:1417399965
Name:WILLOW GROVE FAMILY DENTAL
Entity Type:Organization
Organization Name:WILLOW GROVE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUDSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-694-0222
Mailing Address - Street 1:28 NATHAN LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6306
Mailing Address - Country:US
Mailing Address - Phone:763-544-5555
Mailing Address - Fax:763-544-0305
Practice Address - Street 1:28 NATHAN LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6306
Practice Address - Country:US
Practice Address - Phone:763-544-5555
Practice Address - Fax:763-544-0305
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GR SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-25
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherEMPLOYER ID NUMBER (EIN)