Provider Demographics
NPI:1245303254
Name:ELK RIVER FAMILY DENTISTRY
Entity type:Organization
Organization Name:ELK RIVER FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:NYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-441-9181
Mailing Address - Street 1:303 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330
Mailing Address - Country:US
Mailing Address - Phone:763-441-9181
Mailing Address - Fax:763-441-3399
Practice Address - Street 1:303 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330
Practice Address - Country:US
Practice Address - Phone:763-441-9181
Practice Address - Fax:763-441-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty