Provider Demographics
NPI:1679947287
Name:PURE DENTAL
Entity Type:Organization
Organization Name:PURE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-329-5141
Mailing Address - Street 1:6230 10TH ST N
Mailing Address - Street 2:SUITE #520
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6158
Mailing Address - Country:US
Mailing Address - Phone:651-731-3064
Mailing Address - Fax:651-731-9340
Practice Address - Street 1:6230 10TH ST N
Practice Address - Street 2:SUITE #520
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6158
Practice Address - Country:US
Practice Address - Phone:651-731-3064
Practice Address - Fax:651-731-9340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12647122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty