Provider Demographics
NPI:1982877064
Name:DENTAL HEALTH CENTER OF MN
Entity Type:Organization
Organization Name:DENTAL HEALTH CENTER OF MN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:
Authorized Official - First Name:SOLONGO
Authorized Official - Middle Name:
Authorized Official - Last Name:PUREV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-929-2388
Mailing Address - Street 1:4820 MINNETONKA BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5707
Mailing Address - Country:US
Mailing Address - Phone:952-929-2388
Mailing Address - Fax:
Practice Address - Street 1:4820 MINNETONKA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5707
Practice Address - Country:US
Practice Address - Phone:952-929-2388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11735302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization