Provider Demographics
NPI:1063752483
Name:RICHFIELD PEDIATRIC DENTISTRY, P.A.
Entity type:Organization
Organization Name:RICHFIELD PEDIATRIC DENTISTRY, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-475-3135
Mailing Address - Street 1:250 CENTRAL AVE N
Mailing Address - Street 2:SUITE 113
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1206
Mailing Address - Country:US
Mailing Address - Phone:952-475-3135
Mailing Address - Fax:
Practice Address - Street 1:6945 PENN AVE S
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2081
Practice Address - Country:US
Practice Address - Phone:612-866-4041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAYLOR J. STEPHENS, D.D.S, P.A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-21
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12818261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental