Provider Demographics
NPI:1619451192
Name:MINNESOTA DENTAL PROFESSIONALS, P.C.
Entity Type:Organization
Organization Name:MINNESOTA DENTAL PROFESSIONALS, P.C.
Other - Org Name:SOUTHWEST DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8426
Mailing Address - Street 1:107 12TH ST SW STE 2
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-1467
Mailing Address - Country:US
Mailing Address - Phone:651-964-2013
Mailing Address - Fax:651-272-5323
Practice Address - Street 1:107 12TH ST SW STE 2
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1467
Practice Address - Country:US
Practice Address - Phone:612-261-4998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-20
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty