Provider Demographics
NPI:1639334428
Name:BRYAN J. OPHAUG, D.D.S., P.A.
Entity Type:Organization
Organization Name:BRYAN J. OPHAUG, D.D.S., P.A.
Other - Org Name:BASS LAKE DENTAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:OPHAUG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-533-5359
Mailing Address - Street 1:7123 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3822
Mailing Address - Country:US
Mailing Address - Phone:763-533-5359
Mailing Address - Fax:763-533-0010
Practice Address - Street 1:7123 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3822
Practice Address - Country:US
Practice Address - Phone:763-533-5359
Practice Address - Fax:763-533-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND118901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty