Provider Demographics
NPI:1336361534
Name:NORTHTOWN CENTER DENTAL CENTER
Entity Type:Organization
Organization Name:NORTHTOWN CENTER DENTAL CENTER
Other - Org Name:NORTHTOWN DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:NEMETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-780-5007
Mailing Address - Street 1:113 NORTHTOWN DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-1036
Mailing Address - Country:US
Mailing Address - Phone:763-780-5007
Mailing Address - Fax:
Practice Address - Street 1:113 NORTHTOWN DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-1036
Practice Address - Country:US
Practice Address - Phone:763-780-5007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9392122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty