Provider Demographics
NPI:1619287562
Name:NORTHDALE DENTIST PA
Entity Type:Organization
Organization Name:NORTHDALE DENTIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAGANNATIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMAKRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:BDS
Authorized Official - Phone:763-218-2887
Mailing Address - Street 1:6808, 67TH STREET NE.
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301
Mailing Address - Country:US
Mailing Address - Phone:763-218-2887
Mailing Address - Fax:763-463-7807
Practice Address - Street 1:2147, NORTHDALE BLVD NW.
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-497-6977
Practice Address - Fax:763-463-7807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty