Provider Demographics
NPI:1518086750
Name:DENTAL HEALTH SERVICE OF NORTHERN MINNESOTA PA
Entity Type:Organization
Organization Name:DENTAL HEALTH SERVICE OF NORTHERN MINNESOTA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-263-8381
Mailing Address - Street 1:802 W 42ND ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746
Mailing Address - Country:US
Mailing Address - Phone:218-263-8381
Mailing Address - Fax:218-263-8383
Practice Address - Street 1:802 W 42ND ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746
Practice Address - Country:US
Practice Address - Phone:218-263-8381
Practice Address - Fax:218-263-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69151DEOtherBLUE CROSS BLUE SHIELD
MN69151DEOtherBLUE CROSS BLUE SHIELD