Provider Demographics
NPI:1063841559
Name:YOUNG AT HEART DENTISTRY
Entity type:Organization
Organization Name:YOUNG AT HEART DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:DARIN
Authorized Official - Last Name:THIERY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-763-3113
Mailing Address - Street 1:111 10TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-1857
Mailing Address - Country:US
Mailing Address - Phone:320-763-3113
Mailing Address - Fax:320-759-1401
Practice Address - Street 1:111 10TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1857
Practice Address - Country:US
Practice Address - Phone:320-763-3113
Practice Address - Fax:320-759-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11247122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty