Provider Demographics
NPI:1508201997
Name:INTEGRA DENTAL PA
Entity Type:Organization
Organization Name:INTEGRA DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-384-0527
Mailing Address - Street 1:13783 IBIS ST NW
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4892
Mailing Address - Country:US
Mailing Address - Phone:612-384-0527
Mailing Address - Fax:
Practice Address - Street 1:13783 IBIS ST NW
Practice Address - Street 2:SUITE 400
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-4892
Practice Address - Country:US
Practice Address - Phone:612-384-0527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12655122300000X
MND13123122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty