Provider Demographics
NPI:1104977222
Name:MINNEHAHA FALL FAMILY DENTAL
Entity type:Organization
Organization Name:MINNEHAHA FALL FAMILY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-761-2259
Mailing Address - Street 1:4554 MINNEHAHA AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406
Mailing Address - Country:US
Mailing Address - Phone:612-721-3012
Mailing Address - Fax:
Practice Address - Street 1:4554 MINNEHAHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406
Practice Address - Country:US
Practice Address - Phone:612-721-3012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10142122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty