Provider Demographics
NPI:1609272822
Name:ROCHESTER PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:ROCHESTER PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-206-1233
Mailing Address - Street 1:1705 S BORADWAY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-7960
Mailing Address - Country:US
Mailing Address - Phone:507-288-0102
Mailing Address - Fax:507-252-1445
Practice Address - Street 1:1705 S BORADWAY AVE STE B
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-7960
Practice Address - Country:US
Practice Address - Phone:507-288-0102
Practice Address - Fax:507-252-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-16
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND131201223P0221X
1223P0221X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty