Provider Demographics
NPI:1881798155
Name:BELLE PLAINE FAMILY DENTAL PA
Entity type:Organization
Organization Name:BELLE PLAINE FAMILY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-873-2796
Mailing Address - Street 1:210 N MERIDIAN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BELLE PLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:56011-1828
Mailing Address - Country:US
Mailing Address - Phone:952-873-2796
Mailing Address - Fax:952-873-5675
Practice Address - Street 1:210 N MERIDIAN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BELLE PLAINE
Practice Address - State:MN
Practice Address - Zip Code:56011-1828
Practice Address - Country:US
Practice Address - Phone:952-873-2796
Practice Address - Fax:952-873-5675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND105251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty