Provider Demographics
NPI:1538112180
Name:CHANHASSEN DENTAL
Entity Type:Organization
Organization Name:CHANHASSEN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOLEEN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-934-3383
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-0189
Mailing Address - Country:US
Mailing Address - Phone:952-934-3383
Mailing Address - Fax:952-934-6668
Practice Address - Street 1:480 W 78TH ST
Practice Address - Street 2:SUITE #116
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4527
Practice Address - Country:US
Practice Address - Phone:952-934-3383
Practice Address - Fax:952-934-6668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN79511223G0001X
MN105191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty