Provider Demographics
NPI:1972636777
Name:FAMILY DENTIST TREE, PA
Entity type:Organization
Organization Name:FAMILY DENTIST TREE, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-288-1188
Mailing Address - Street 1:1011 BEL AIR LN NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-6992
Mailing Address - Country:US
Mailing Address - Phone:507-288-1188
Mailing Address - Fax:507-529-4065
Practice Address - Street 1:1011 BEL AIR LN NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-6992
Practice Address - Country:US
Practice Address - Phone:507-288-1188
Practice Address - Fax:507-529-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty