Provider Demographics
NPI:1891100772
Name:COMMUNITY DENTAL CARE
Entity Type:Organization
Organization Name:COMMUNITY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:GRABOUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:D D S
Authorized Official - Phone:712-253-5703
Mailing Address - Street 1:3191 LAKERIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-6565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1926 COLLEGEVIEW RD E
Practice Address - Street 2:HC #116
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-8201
Practice Address - Country:US
Practice Address - Phone:507-258-4046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND134371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty