Provider Demographics
NPI:1922619162
Name:BIRCH LAKE DENTAL
Entity Type:Organization
Organization Name:BIRCH LAKE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEETHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAMODARAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-429-0404
Mailing Address - Street 1:4641 WHITE BEAR PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3300
Mailing Address - Country:US
Mailing Address - Phone:651-429-0404
Mailing Address - Fax:
Practice Address - Street 1:4641 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3300
Practice Address - Country:US
Practice Address - Phone:651-429-0404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental