Provider Demographics
NPI:1790088680
Name:GRANITE FALLS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GRANITE FALLS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:ZENK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-269-6416
Mailing Address - Street 1:1265 6TH ST
Mailing Address - Street 2:GRANITE FALLS FAMILY DENTISTRY
Mailing Address - City:GRANITE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56241
Mailing Address - Country:US
Mailing Address - Phone:320-269-6416
Mailing Address - Fax:
Practice Address - Street 1:1265 6TH ST
Practice Address - Street 2:GRANITE FALLS FAMILY DENTISTRY
Practice Address - City:GRANITE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56241
Practice Address - Country:US
Practice Address - Phone:320-269-6416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTEVIDEO FAMILY DENTISTRY, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89081223G0001X
MND109421223G0001X
MND123321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty