Provider Demographics
NPI:1750861258
Name:RIVERS EDGE DENTAL CLINIC, PLLC
Entity type:Organization
Organization Name:RIVERS EDGE DENTAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-232-6454
Mailing Address - Street 1:16023 ELMHURST LN STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4791
Mailing Address - Country:US
Mailing Address - Phone:952-232-6454
Mailing Address - Fax:651-460-6123
Practice Address - Street 1:16023 ELMHURST LN STE 104
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-4791
Practice Address - Country:US
Practice Address - Phone:952-232-6454
Practice Address - Fax:651-460-6123
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERS EDGE DENTAL CLINIC, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental