Provider Demographics
NPI:1669634812
Name:THE DENTISTS HOUSE LLC
Entity Type:Organization
Organization Name:THE DENTISTS HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTISTS
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LAVERN
Authorized Official - Last Name:OHLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR
Authorized Official - Phone:507-334-7471
Mailing Address - Street 1:505 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5032
Mailing Address - Country:US
Mailing Address - Phone:507-334-7471
Mailing Address - Fax:507-334-9736
Practice Address - Street 1:505 4TH ST NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5032
Practice Address - Country:US
Practice Address - Phone:507-334-7471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND102961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN273522900OtherMEDICAL ASSISTANCE