Provider Demographics
NPI:1770213639
Name:PUBLIC HEALTH DENTAL LLC
Entity Type:Organization
Organization Name:PUBLIC HEALTH DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCED DENTAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:DERDIE
Authorized Official - Last Name:O'SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-801-5203
Mailing Address - Street 1:385 S OWASSO BLVD W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:385 S OWASSO BLVD W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2119
Practice Address - Country:US
Practice Address - Phone:612-801-5203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental