Provider Demographics
NPI:1881864049
Name:WADENA FAMILY DENTAL, P. A.
Entity Type:Organization
Organization Name:WADENA FAMILY DENTAL, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-631-4525
Mailing Address - Street 1:122 COLFAX AVE SW
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1470
Mailing Address - Country:US
Mailing Address - Phone:218-631-4525
Mailing Address - Fax:218-631-3998
Practice Address - Street 1:122 COLFAX AVE SW
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1470
Practice Address - Country:US
Practice Address - Phone:218-631-4525
Practice Address - Fax:218-631-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty