Provider Demographics
NPI:1518141548
Name:BIG LAKE DENTAL, PA
Entity Type:Organization
Organization Name:BIG LAKE DENTAL, PA
Other - Org Name:SAND PRAIRIE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROMAGHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-263-6350
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-0249
Mailing Address - Country:US
Mailing Address - Phone:763-263-6350
Mailing Address - Fax:763-263-0136
Practice Address - Street 1:16991 198TH AVENUE NW
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-0249
Practice Address - Country:US
Practice Address - Phone:763-263-6350
Practice Address - Fax:763-263-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND93551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty