Provider Demographics
NPI:1932247921
Name:SOUTHERN HEIGHTS DENTAL GROUP PA
Entity Type:Organization
Organization Name:SOUTHERN HEIGHTS DENTAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:TONJUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-334-6433
Mailing Address - Street 1:1575 20TH STREET NORTHWEST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021
Mailing Address - Country:US
Mailing Address - Phone:507-334-6433
Mailing Address - Fax:507-334-0044
Practice Address - Street 1:1575 20TH STREET NORTHWEST
Practice Address - Street 2:SUITE 102
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:507-334-6433
Practice Address - Fax:507-334-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND78001223G0001X, 261QD0000X, 1223G0001X
MND98841223G0001X
MND103231223G0001X
MND115861223G0001X
MND114001223G0001X
MND116311223G0001X
MND87421223G0001X
MND13095261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN550722700Medicaid
MN607320400Medicaid
MN148427300Medicaid
MN284735300Medicaid
MN856415900Medicaid
MN325522100Medicaid
MN440217100Medicaid
MN443655000Medicaid
MN849698600Medicaid