Provider Demographics
NPI:1760592406
Name:ELK PLAZA DENTAL
Entity Type:Organization
Organization Name:ELK PLAZA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-441-4200
Mailing Address - Street 1:501 MAIN ST NW
Mailing Address - Street 2:#101
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1880
Mailing Address - Country:US
Mailing Address - Phone:763-441-4200
Mailing Address - Fax:
Practice Address - Street 1:501 MAIN ST NW
Practice Address - Street 2:#101
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1880
Practice Address - Country:US
Practice Address - Phone:763-441-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty