Provider Demographics
NPI:1881972560
Name:WOODDALE DENTAL CENTER, LLC
Entity type:Organization
Organization Name:WOODDALE DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JELENA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-929-3336
Mailing Address - Street 1:3401 WOODDALE AVE S STE 1
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2341
Mailing Address - Country:US
Mailing Address - Phone:952-929-3336
Mailing Address - Fax:952-929-3338
Practice Address - Street 1:3401 WOODDALE AVE S STE 1
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2341
Practice Address - Country:US
Practice Address - Phone:952-929-3336
Practice Address - Fax:952-929-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12163261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1437219813OtherNPI TYPE 1