Provider Demographics
NPI:1811943061
Name:LONG PRAIRIE DENTAL CLINIC LLC
Entity type:Organization
Organization Name:LONG PRAIRIE DENTAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-732-6141
Mailing Address - Street 1:917 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347
Mailing Address - Country:US
Mailing Address - Phone:320-732-6141
Mailing Address - Fax:320-732-6543
Practice Address - Street 1:917 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347
Practice Address - Country:US
Practice Address - Phone:320-732-6141
Practice Address - Fax:320-732-6543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty