Provider Demographics
NPI: | 1538328059 |
---|---|
Name: | LAKELAND FAMILY DENTAL |
Entity Type: | Organization |
Organization Name: | LAKELAND FAMILY DENTAL |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | FU |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | WONG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 763-424-4415 |
Mailing Address - Street 1: | 106 BROADWAY ST EAST |
Mailing Address - Street 2: | |
Mailing Address - City: | MONTICELLO |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55362-9351 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 763-295-3036 |
Mailing Address - Fax: | 763-295-4514 |
Practice Address - Street 1: | 106 BROADWAY STREET EAST |
Practice Address - Street 2: | |
Practice Address - City: | MONTICELLO |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55362 |
Practice Address - Country: | US |
Practice Address - Phone: | 763-295-3036 |
Practice Address - Fax: | 763-295-4514 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | FU WONG DDS |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2008-06-09 |
Last Update Date: | 2008-06-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 10739 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |