Provider Demographics
NPI:1063559540
Name:DAKOTA DENTAL CLINIC PA
Entity type:Organization
Organization Name:DAKOTA DENTAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ISABELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-431-5774
Mailing Address - Street 1:14682 PENNOCK AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7429
Mailing Address - Country:US
Mailing Address - Phone:952-431-5774
Mailing Address - Fax:952-431-0862
Practice Address - Street 1:14682 PENNOCK AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7429
Practice Address - Country:US
Practice Address - Phone:952-431-5774
Practice Address - Fax:952-431-0862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND94281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty