Provider Demographics
NPI:1700065687
Name:MORA DENTAL CENTER
Entity Type:Organization
Organization Name:MORA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RENY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-679-2147
Mailing Address - Street 1:547 UNION ST S
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1817
Mailing Address - Country:US
Mailing Address - Phone:320-679-2147
Mailing Address - Fax:320-679-2101
Practice Address - Street 1:547 UNION ST S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1817
Practice Address - Country:US
Practice Address - Phone:320-679-2147
Practice Address - Fax:320-679-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11844261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental