Provider Demographics
NPI:1417469198
Name:PERRY DENTAL, LTD
Entity Type:Organization
Organization Name:PERRY DENTAL, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-585-5200
Mailing Address - Street 1:515 JEFFERSON AVE S.W.
Mailing Address - Street 2:
Mailing Address - City:EYOTA
Mailing Address - State:MN
Mailing Address - Zip Code:55934
Mailing Address - Country:US
Mailing Address - Phone:507-585-5200
Mailing Address - Fax:507-585-5202
Practice Address - Street 1:515 JEFFERSON AVE S.W.
Practice Address - Street 2:
Practice Address - City:EYOTA
Practice Address - State:MN
Practice Address - Zip Code:55934
Practice Address - Country:US
Practice Address - Phone:507-585-5200
Practice Address - Fax:507-585-5202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERRY DENTAL, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND128261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty