Provider Demographics
NPI:1477888949
Name:BYRON DENTAL GROUP PA
Entity Type:Organization
Organization Name:BYRON DENTAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STACKHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-775-6445
Mailing Address - Street 1:P.O. BOX 37
Mailing Address - Street 2:21 NE FRONTAGE RD.,
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920
Mailing Address - Country:US
Mailing Address - Phone:507-775-6445
Mailing Address - Fax:507-775-6446
Practice Address - Street 1:21 NE FRONTAGE RD.
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:MN
Practice Address - Zip Code:55920
Practice Address - Country:US
Practice Address - Phone:507-775-6445
Practice Address - Fax:507-775-6446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty