Provider Demographics
NPI:1790856847
Name:ALBERT LEA DENTAL CLINIC PA
Entity type:Organization
Organization Name:ALBERT LEA DENTAL CLINIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:HEROLD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-373-5968
Mailing Address - Street 1:1206 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-1903
Mailing Address - Country:US
Mailing Address - Phone:507-373-5968
Mailing Address - Fax:507-373-8410
Practice Address - Street 1:1206 W FRONT ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-1903
Practice Address - Country:US
Practice Address - Phone:507-373-5968
Practice Address - Fax:507-373-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-12
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental