Provider Demographics
NPI:1811143936
Name:NEW PRAGUE DENTAL CENTER
Entity type:Organization
Organization Name:NEW PRAGUE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-758-4741
Mailing Address - Street 1:101 LEXINGTON AVE S.
Mailing Address - Street 2:
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071
Mailing Address - Country:US
Mailing Address - Phone:952-758-4741
Mailing Address - Fax:952-758-4740
Practice Address - Street 1:101 LEXINGTON AVE S.
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071
Practice Address - Country:US
Practice Address - Phone:952-758-4741
Practice Address - Fax:952-758-4740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND108251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty