Provider Demographics
NPI:1639485634
Name:GREAT RIVER ENDODONTICS, PA
Entity Type:Organization
Organization Name:GREAT RIVER ENDODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KARN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:763-497-0082
Mailing Address - Street 1:750 CENTRAL AVE E
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4552
Mailing Address - Country:US
Mailing Address - Phone:763-497-0082
Mailing Address - Fax:763-497-0084
Practice Address - Street 1:750 CENTRAL AVE E
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-4552
Practice Address - Country:US
Practice Address - Phone:763-497-0082
Practice Address - Fax:763-497-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122E0200X1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty