Provider Demographics
NPI:1972748721
Name:CENTENNIAL LAKES DENTAL GROUP
Entity Type:Organization
Organization Name:CENTENNIAL LAKES DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SLAVIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-831-2800
Mailing Address - Street 1:5851 DULUTH ST STE 218
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3956
Mailing Address - Country:US
Mailing Address - Phone:763-544-0121
Mailing Address - Fax:763-544-2727
Practice Address - Street 1:5851 DULUTH ST STE 218
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-3956
Practice Address - Country:US
Practice Address - Phone:763-544-0121
Practice Address - Fax:763-544-2727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty