Provider Demographics
NPI:1841462652
Name:MAHTOMEDI DENTAL CLINIC
Entity type:Organization
Organization Name:MAHTOMEDI DENTAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER - DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MPH
Authorized Official - Phone:651-426-0011
Mailing Address - Street 1:814 MAHTOMEDI AVE
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1730
Mailing Address - Country:US
Mailing Address - Phone:651-426-0011
Mailing Address - Fax:651-426-2075
Practice Address - Street 1:814 MAHTOMEDI AVE
Practice Address - Street 2:MAHTOMEDI DENTAL
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-1730
Practice Address - Country:US
Practice Address - Phone:651-426-0011
Practice Address - Fax:651-426-2075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113961223G0001X
MND82171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN982017500Medicaid