Provider Demographics
NPI:1912303777
Name:LICENSED DENTAL HYGIENE CARE
Entity Type:Organization
Organization Name:LICENSED DENTAL HYGIENE CARE
Other - Org Name:SENIOR MOBILE DENTAL MINNESOTA LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:VACHA
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:763-545-7545
Mailing Address - Street 1:5201 EDEN AVE
Mailing Address - Street 2:SUITE 50
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2316
Mailing Address - Country:US
Mailing Address - Phone:763-545-7545
Mailing Address - Fax:952-929-2067
Practice Address - Street 1:5201 EDEN AVE
Practice Address - Street 2:SUITE 50
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2316
Practice Address - Country:US
Practice Address - Phone:763-545-7545
Practice Address - Fax:952-929-2067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND126961223G0001X
CO20071454175251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No251V00000XAgenciesVoluntary or CharitableGroup - Single Specialty