Provider Demographics
NPI:1093607764
Name:PLUM TREE DENTAL
Entity type:Organization
Organization Name:PLUM TREE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:218-749-1776
Mailing Address - Street 1:202 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2638
Mailing Address - Country:US
Mailing Address - Phone:218-749-1776
Mailing Address - Fax:218-749-0866
Practice Address - Street 1:202 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2638
Practice Address - Country:US
Practice Address - Phone:218-749-1776
Practice Address - Fax:218-749-0866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty