Provider Demographics
NPI:1700136116
Name:MAIN STREET DENTAL OF KENYON PA
Entity Type:Organization
Organization Name:MAIN STREET DENTAL OF KENYON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DUY
Authorized Official - Middle Name:
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-235-6604
Mailing Address - Street 1:216 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:KENYON
Mailing Address - State:MN
Mailing Address - Zip Code:55946-1151
Mailing Address - Country:US
Mailing Address - Phone:507-789-6815
Mailing Address - Fax:
Practice Address - Street 1:216 FOREST ST
Practice Address - Street 2:
Practice Address - City:KENYON
Practice Address - State:MN
Practice Address - Zip Code:55946
Practice Address - Country:US
Practice Address - Phone:507-789-6815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12683261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental