Provider Demographics
NPI:1720484496
Name:ROOT RIVER DENTAL, PA
Entity Type:Organization
Organization Name:ROOT RIVER DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LECHNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-493-0424
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:STEWARTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55976-0008
Mailing Address - Country:US
Mailing Address - Phone:507-533-7735
Mailing Address - Fax:507-533-8852
Practice Address - Street 1:100 2ND ST SE
Practice Address - Street 2:
Practice Address - City:STEWARTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55976-1288
Practice Address - Country:US
Practice Address - Phone:507-533-7735
Practice Address - Fax:507-533-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND45964261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN837637000Medicaid