Provider Demographics
NPI:1609098458
Name:RIVER BLUFF DENTAL, P.A.
Entity Type:Organization
Organization Name:RIVER BLUFF DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST & OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-884-5361
Mailing Address - Street 1:10851 RHODE ISLAND AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2393
Mailing Address - Country:US
Mailing Address - Phone:952-884-5361
Mailing Address - Fax:952-946-9533
Practice Address - Street 1:10851 RHODE ISLAND AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-2393
Practice Address - Country:US
Practice Address - Phone:952-884-5361
Practice Address - Fax:952-946-9533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty