Provider Demographics
NPI:1730655242
Name:ROUND LAKE FAMILY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:ROUND LAKE FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:ZHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-308-9416
Mailing Address - Street 1:7493 147TH ST W STE 100
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7570
Mailing Address - Country:US
Mailing Address - Phone:952-432-7145
Mailing Address - Fax:
Practice Address - Street 1:13841 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3664
Practice Address - Country:US
Practice Address - Phone:763-427-0285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental