Provider Demographics
NPI:1891749362
Name:EAGAN DENTAL ASSOCIATES DBA NORTHWOOD DENTAL
Entity Type:Organization
Organization Name:EAGAN DENTAL ASSOCIATES DBA NORTHWOOD DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:TAPLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-687-0789
Mailing Address - Street 1:1227 NORTHWOOD PKWY
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-4204
Mailing Address - Country:US
Mailing Address - Phone:651-687-0789
Mailing Address - Fax:651-687-0902
Practice Address - Street 1:1227 NORTHWOOD PKWY
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-4204
Practice Address - Country:US
Practice Address - Phone:651-687-0789
Practice Address - Fax:651-687-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1891749362Medicaid
MN405522500Medicaid
MN565522600Medicaid