Provider Demographics
NPI:1811327190
Name:DREAMHAVEN DENTAL SLEEP MEDICINE
Entity type:Organization
Organization Name:DREAMHAVEN DENTAL SLEEP MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-454-0523
Mailing Address - Street 1:13495 ELDER DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425
Mailing Address - Country:US
Mailing Address - Phone:218-454-0523
Mailing Address - Fax:
Practice Address - Street 1:13495 ELDER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8763
Practice Address - Country:US
Practice Address - Phone:218-454-0523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10518261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental