Provider Demographics
NPI:1336568781
Name:VIRGINIA FAMILY DENTAL P.A.
Entity Type:Organization
Organization Name:VIRGINIA FAMILY DENTAL P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:MISKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-741-0405
Mailing Address - Street 1:802 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2451
Mailing Address - Country:US
Mailing Address - Phone:218-741-0405
Mailing Address - Fax:218-741-1445
Practice Address - Street 1:802 4TH ST N
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2451
Practice Address - Country:US
Practice Address - Phone:218-741-0405
Practice Address - Fax:218-741-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12649261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental