Provider Demographics
NPI:1134574163
Name:LONG LAKE FAMILY DENISTRY
Entity type:Organization
Organization Name:LONG LAKE FAMILY DENISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOSSEIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JALALI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-633-1311
Mailing Address - Street 1:991 9TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-2665
Mailing Address - Country:US
Mailing Address - Phone:651-633-1311
Mailing Address - Fax:651-633-4339
Practice Address - Street 1:991 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-2665
Practice Address - Country:US
Practice Address - Phone:651-633-1311
Practice Address - Fax:651-633-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND134801223G0001X
MN104651223S0112X
MN102561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty