Provider Demographics
NPI:1750774428
Name:BUCCA DENTAL LLC
Entity type:Organization
Organization Name:BUCCA DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:FERNANDO
Authorized Official - Last Name:MANTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-724-1717
Mailing Address - Street 1:1508 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1720
Mailing Address - Country:US
Mailing Address - Phone:612-724-1717
Mailing Address - Fax:612-724-3114
Practice Address - Street 1:1508 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1720
Practice Address - Country:US
Practice Address - Phone:612-724-1717
Practice Address - Fax:612-724-3114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11889261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental