Provider Demographics
NPI:1770645145
Name:COUNTY OF MURRAY
Entity Type:Organization
Organization Name:COUNTY OF MURRAY
Other - Org Name:SHETEK DENTAL CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NARLA
Authorized Official - Middle Name:N
Authorized Official - Last Name:HULSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-836-1000
Mailing Address - Street 1:2711 BROADWAY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SLAYTON
Mailing Address - State:MN
Mailing Address - Zip Code:56172-1313
Mailing Address - Country:US
Mailing Address - Phone:507-836-1000
Mailing Address - Fax:507-836-1008
Practice Address - Street 1:2711 BROADWAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:SLAYTON
Practice Address - State:MN
Practice Address - Zip Code:56172-1313
Practice Address - Country:US
Practice Address - Phone:507-836-1000
Practice Address - Fax:507-836-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN80270571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN791987500Medicaid