Provider Demographics
NPI:1376676445
Name:ROUND LAKE DENTAL P.A.
Entity type:Organization
Organization Name:ROUND LAKE DENTAL P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-427-0285
Mailing Address - Street 1:13841 ROUND LAKE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3664
Mailing Address - Country:US
Mailing Address - Phone:763-427-0285
Mailing Address - Fax:763-576-0156
Practice Address - Street 1:13841 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3664
Practice Address - Country:US
Practice Address - Phone:763-427-0285
Practice Address - Fax:763-576-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND103391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty