Provider Demographics
NPI:1568648871
Name:DAN M. PROESCHEL
Entity Type:Organization
Organization Name:DAN M. PROESCHEL
Other - Org Name:LAKE NOKOMIS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PROESCHEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-729-6150
Mailing Address - Street 1:4927 34TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1552
Mailing Address - Country:US
Mailing Address - Phone:612-729-6150
Mailing Address - Fax:612-722-8817
Practice Address - Street 1:4927 34TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-1552
Practice Address - Country:US
Practice Address - Phone:612-729-6150
Practice Address - Fax:612-722-8817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND79261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty