Provider Demographics
NPI:1639486285
Name:FRIENDLY DENTAL
Entity Type:Organization
Organization Name:FRIENDLY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JARI
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-376-5525
Mailing Address - Street 1:611 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SIBLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51249-1626
Mailing Address - Country:US
Mailing Address - Phone:712-754-2288
Mailing Address - Fax:712-754-4865
Practice Address - Street 1:611 3RD AVE
Practice Address - Street 2:
Practice Address - City:SIBLEY
Practice Address - State:IA
Practice Address - Zip Code:51249-1626
Practice Address - Country:US
Practice Address - Phone:712-754-2288
Practice Address - Fax:712-754-4865
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRIENDLY DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07092261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1922167410OtherINDIVIDUAL NPI KELLY PHILLIPS, DDS
MN1316975568OtherINDIVIDUAL NPI JERRY L. JOHNSON, DDS
MN1770672958OtherPRIMARY LOCATION NPI