Provider Demographics
NPI:1841915741
Name:NICOLLET FAMILY DENTISTRY
Entity type:Organization
Organization Name:NICOLLET FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:ROSEANN
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-870-4646
Mailing Address - Street 1:2738 WINNETKA AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2877
Mailing Address - Country:US
Mailing Address - Phone:612-870-4646
Mailing Address - Fax:763-717-8491
Practice Address - Street 1:2738 WINNETKA AVE N STE 100
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-2877
Practice Address - Country:US
Practice Address - Phone:612-870-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental