Provider Demographics
NPI:1982308847
Name:RIVERSIDE FAMILY DENTAL, P.A.
Entity Type:Organization
Organization Name:RIVERSIDE FAMILY DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAKHREDDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-427-7930
Mailing Address - Street 1:2006 1ST AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2255
Mailing Address - Country:US
Mailing Address - Phone:763-427-7930
Mailing Address - Fax:
Practice Address - Street 1:2006 1ST AVE STE 202
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2255
Practice Address - Country:US
Practice Address - Phone:763-427-7930
Practice Address - Fax:763-427-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental