Provider Demographics
NPI:1700945672
Name:WATERFRONT FAMILY DENTISTRY PA
Entity Type:Organization
Organization Name:WATERFRONT FAMILY DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-454-1628
Mailing Address - Street 1:50 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3440
Mailing Address - Country:US
Mailing Address - Phone:507-454-1628
Mailing Address - Fax:507-453-7841
Practice Address - Street 1:50 W 2ND ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3440
Practice Address - Country:US
Practice Address - Phone:507-454-1628
Practice Address - Fax:507-453-7841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty