Provider Demographics
NPI:1740400985
Name:LAKE SUPERIOR COLLEGE DENTAL CLINIC
Entity Type:Organization
Organization Name:LAKE SUPERIOR COLLEGE DENTAL CLINIC
Other - Org Name:LAKE SUPERIOR DENTAL HYGIENE LAKE SUPERIOR COMMUNITY DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTAL HYGIENE CLINIC COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:UPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-733-5939
Mailing Address - Street 1:2101 TRINITY ROAD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3349
Mailing Address - Country:US
Mailing Address - Phone:218-733-5939
Mailing Address - Fax:218-723-4921
Practice Address - Street 1:2101 TRINITY ROAD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-3349
Practice Address - Country:US
Practice Address - Phone:218-733-5939
Practice Address - Fax:218-723-4921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental