Provider Demographics
NPI:1184923096
Name:GLACIAL LAKES DENTAL, PLLP
Entity type:Organization
Organization Name:GLACIAL LAKES DENTAL, PLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:PLATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-235-7742
Mailing Address - Street 1:509 16TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4118
Mailing Address - Country:US
Mailing Address - Phone:320-235-7742
Mailing Address - Fax:320-235-4045
Practice Address - Street 1:509 16TH AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4118
Practice Address - Country:US
Practice Address - Phone:320-235-7742
Practice Address - Fax:320-235-4045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental