Provider Demographics
NPI:1558858803
Name:BLUFFSIDE DENTAL
Entity Type:Organization
Organization Name:BLUFFSIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DD
Authorized Official - Phone:952-892-5050
Mailing Address - Street 1:50 MCANDREWS RD E
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5718
Mailing Address - Country:US
Mailing Address - Phone:952-892-5050
Mailing Address - Fax:
Practice Address - Street 1:424 W 5TH ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2524
Practice Address - Country:US
Practice Address - Phone:651-388-5492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-21
Last Update Date:2018-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11535122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty