Provider Demographics
NPI:1356539993
Name:WOODGROVE DENTAL PA
Entity type:Organization
Organization Name:WOODGROVE DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HENSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-738-1284
Mailing Address - Street 1:1789 WOODLANE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3910
Mailing Address - Country:US
Mailing Address - Phone:651-738-1284
Mailing Address - Fax:651-738-0072
Practice Address - Street 1:1789 WOODLANE DR
Practice Address - Street 2:SUITE D
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3910
Practice Address - Country:US
Practice Address - Phone:651-738-1284
Practice Address - Fax:651-738-0072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND95441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty