Provider Demographics
NPI:1447583778
Name:LONE OAK FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LONE OAK FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HANEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-745-4601
Mailing Address - Street 1:205 W JOHNSON AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WARREN
Mailing Address - State:MN
Mailing Address - Zip Code:56762-1118
Mailing Address - Country:US
Mailing Address - Phone:218-745-4601
Mailing Address - Fax:
Practice Address - Street 1:205 W JOHNSON AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-1118
Practice Address - Country:US
Practice Address - Phone:218-745-4601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KITTSON DENTAL CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12024302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN472990600Medicare PIN