Provider Demographics
NPI:1912013640
Name:MANKATO FAMILY DENTAL, P.A.
Entity Type:Organization
Organization Name:MANKATO FAMILY DENTAL, P.A.
Other - Org Name:BROAD STREET FAMILY DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:MEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-345-4259
Mailing Address - Street 1:151 ST ANDREWS CT STE 1120
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-345-4259
Mailing Address - Fax:507-345-4460
Practice Address - Street 1:151 ST ANDREWS CT STE 1120
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-345-4259
Practice Address - Fax:507-345-4460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100091223G0001X
MN121481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1770572877OtherOTHER PROVIDER UNDER CORP
MN1285610022OtherINDIVIDUAL UNDER CORPORAT