Provider Demographics
NPI:1609095140
Name:PLYMOUTH PLAZA DENTAL
Entity Type:Organization
Organization Name:PLYMOUTH PLAZA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-476-6774
Mailing Address - Street 1:1495 COUNTY ROAD 101 N
Mailing Address - Street 2:SUITE2
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-3078
Mailing Address - Country:US
Mailing Address - Phone:763-476-6774
Mailing Address - Fax:763-476-2147
Practice Address - Street 1:1495 COUNTY ROAD 101 N
Practice Address - Street 2:SUITE2
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-3078
Practice Address - Country:US
Practice Address - Phone:763-476-6774
Practice Address - Fax:763-476-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN83201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty