Provider Demographics
NPI:1083458186
Name:CHANHASSEN ENDODONTICS
Entity type:Organization
Organization Name:CHANHASSEN ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MADELEINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:701-898-8640
Mailing Address - Street 1:7770 DELL RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9316
Mailing Address - Country:US
Mailing Address - Phone:952-294-3575
Mailing Address - Fax:
Practice Address - Street 1:7770 DELL RD STE 110
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-9316
Practice Address - Country:US
Practice Address - Phone:952-294-3575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental