Provider Demographics
NPI:1760824486
Name:UNION GOSPEL MISSION
Entity Type:Organization
Organization Name:UNION GOSPEL MISSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOTTERUD
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:651-789-7604
Mailing Address - Street 1:435 UNIVERSITY AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-4437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 UNIVERSITY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4437
Practice Address - Country:US
Practice Address - Phone:651-789-7604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental