Provider Demographics
NPI:1063947307
Name:SORENSON DENTAL
Entity type:Organization
Organization Name:SORENSON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:S
Authorized Official - Last Name:SORENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-204-0201
Mailing Address - Street 1:14688 EVERTON AVE N
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-6064
Mailing Address - Country:US
Mailing Address - Phone:651-204-0201
Mailing Address - Fax:
Practice Address - Street 1:14688 EVERTON AVE N
Practice Address - Street 2:SUITE 104
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-6064
Practice Address - Country:US
Practice Address - Phone:651-204-0201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13363261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental