Provider Demographics
NPI:1265531685
Name:CANNON FALLS DENTAL LLC
Entity type:Organization
Organization Name:CANNON FALLS DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PROCHASKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-263-2411
Mailing Address - Street 1:411 MAIN ST W
Mailing Address - Street 2:P. O. BOX 17
Mailing Address - City:CANNON FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55009-2044
Mailing Address - Country:US
Mailing Address - Phone:507-263-2411
Mailing Address - Fax:507-263-2413
Practice Address - Street 1:411 MAIN ST W
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-2044
Practice Address - Country:US
Practice Address - Phone:507-263-2411
Practice Address - Fax:507-263-2413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty