Provider Demographics
NPI:1558342469
Name:FERGUS FALLS DENTAL GROUP
Entity Type:Organization
Organization Name:FERGUS FALLS DENTAL GROUP
Other - Org Name:DEPARTMENT OF HUMAN SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:MANGER/SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:KVERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-739-7254
Mailing Address - Street 1:1121 PEBBLE LAKE ROAD
Mailing Address - Street 2:PO BOX 503
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537
Mailing Address - Country:US
Mailing Address - Phone:218-739-7254
Mailing Address - Fax:218-739-7253
Practice Address - Street 1:1121 PEBBLE LAKE ROAD
Practice Address - Street 2:BOX 503
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-739-7254
Practice Address - Fax:218-739-7253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN98451223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty