Provider Demographics
NPI:1457570194
Name:SMISEK FAMILY DENTISTRY P.A.
Entity Type:Organization
Organization Name:SMISEK FAMILY DENTISTRY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SMISEK FAMILY DENTISTRY
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:SMISEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-483-6747
Mailing Address - Street 1:501 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-2016
Mailing Address - Country:US
Mailing Address - Phone:651-483-6747
Mailing Address - Fax:651-483-1863
Practice Address - Street 1:501 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2016
Practice Address - Country:US
Practice Address - Phone:651-483-6747
Practice Address - Fax:651-483-1863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN79091223G0001X
MN97831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
41-124-3604OtherFEDERAL ID. NUMBER
MN66340-47OtherSTATE MN ID NUMBER