Provider Demographics
NPI:1104400845
Name:HAM LAKE DENTAL PLLC
Entity type:Organization
Organization Name:HAM LAKE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:SHNAYDRUK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-261-4307
Mailing Address - Street 1:16220 ABERDEEN ST NE STE A1
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5421
Mailing Address - Country:US
Mailing Address - Phone:763-415-7831
Mailing Address - Fax:
Practice Address - Street 1:16220 ABERDEEN ST NE STE A1
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-5421
Practice Address - Country:US
Practice Address - Phone:763-415-7831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental