Provider Demographics
NPI:1619141942
Name:CRYSTAL LAKE DENTAL CARE OF ROBBINSDALE, PLLC
Entity Type:Organization
Organization Name:CRYSTAL LAKE DENTAL CARE OF ROBBINSDALE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAASEDLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-588-8426
Mailing Address - Street 1:3925 37TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2357
Mailing Address - Country:US
Mailing Address - Phone:763-588-8426
Mailing Address - Fax:763-588-0176
Practice Address - Street 1:3925 37TH AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2357
Practice Address - Country:US
Practice Address - Phone:763-588-8426
Practice Address - Fax:763-588-0176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND86501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty