Provider Demographics
NPI:1376386607
Name:GLEN LAKE DENTAL
Entity type:Organization
Organization Name:GLEN LAKE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:TARAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-935-5212
Mailing Address - Street 1:14421 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5821
Mailing Address - Country:US
Mailing Address - Phone:952-935-5212
Mailing Address - Fax:952-935-1391
Practice Address - Street 1:14421 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-5821
Practice Address - Country:US
Practice Address - Phone:952-935-5212
Practice Address - Fax:952-935-1391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental