Provider Demographics
NPI:1831254150
Name:DENTAL DEPOT INC
Entity type:Organization
Organization Name:DENTAL DEPOT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HAUGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-589-4481
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:2 EAST 5TH ST
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267
Mailing Address - Country:US
Mailing Address - Phone:320-589-4481
Mailing Address - Fax:320-589-2750
Practice Address - Street 1:2 E 5TH ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1344
Practice Address - Country:US
Practice Address - Phone:320-589-4481
Practice Address - Fax:320-589-2750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty