Provider Demographics
NPI:1962676825
Name:OTSEGO DENTAL
Entity Type:Organization
Organization Name:OTSEGO DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEILS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-441-2452
Mailing Address - Street 1:9075 QUADAY AVE NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-6672
Mailing Address - Country:US
Mailing Address - Phone:763-441-2452
Mailing Address - Fax:763-441-7675
Practice Address - Street 1:9075 QUADAY AVE NE
Practice Address - Street 2:SUITE 101
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-6672
Practice Address - Country:US
Practice Address - Phone:763-441-2452
Practice Address - Fax:763-441-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty