Provider Demographics
NPI:1669949442
Name:MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.
Entity type:Organization
Organization Name:MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:218-444-9147
Mailing Address - Street 1:1405 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5113
Mailing Address - Country:US
Mailing Address - Phone:218-444-9147
Mailing Address - Fax:
Practice Address - Street 1:132 3RD ST W
Practice Address - Street 2:
Practice Address - City:HALSTAD
Practice Address - State:MN
Practice Address - Zip Code:56548-4015
Practice Address - Country:US
Practice Address - Phone:218-456-2238
Practice Address - Fax:218-456-2248
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental