Provider Demographics
NPI:1720415896
Name:MAHTOMEDI FAMILY DENTAL
Entity Type:Organization
Organization Name:MAHTOMEDI FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-426-0011
Mailing Address - Street 1:814 MAHTOMEDI AVE
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:814 MAHTOMEDI AVE
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-1730
Practice Address - Country:US
Practice Address - Phone:651-426-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND77211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1811212624Medicaid