Provider Demographics
NPI:1699204172
Name:WLD2, LLC
Entity Type:Organization
Organization Name:WLD2, LLC
Other - Org Name:WEST LAKES DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-387-5009
Mailing Address - Street 1:1635 SUNNYBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:MINNETRISTA
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1276
Mailing Address - Country:US
Mailing Address - Phone:1612-387-5009
Mailing Address - Fax:
Practice Address - Street 1:132 PIONEER TRL
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1167
Practice Address - Country:US
Practice Address - Phone:952-361-3740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST LAKES DENTISTRY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11974261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental