Provider Demographics
NPI:1063768687
Name:BLAINE DENTAL LLC DBA PRO DENTAL
Entity type:Organization
Organization Name:BLAINE DENTAL LLC DBA PRO DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BDS
Authorized Official - Prefix:DR
Authorized Official - First Name:ARIF
Authorized Official - Middle Name:
Authorized Official - Last Name:NAZIR
Authorized Official - Suffix:
Authorized Official - Credentials:BDS
Authorized Official - Phone:763-231-2050
Mailing Address - Street 1:10210 BALTIMORE ST NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6049
Mailing Address - Country:US
Mailing Address - Phone:763-231-2050
Mailing Address - Fax:763-231-2052
Practice Address - Street 1:10210 BALTIMORE ST NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-6049
Practice Address - Country:US
Practice Address - Phone:763-231-2050
Practice Address - Fax:763-231-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty