Provider Demographics
NPI:1124096011
Name:FALLS COURT DENTISTS PA
Entity type:Organization
Organization Name:FALLS COURT DENTISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CORP VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GESSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-632-6621
Mailing Address - Street 1:119 NE FIRST STREET
Mailing Address - Street 2:STE 4
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345
Mailing Address - Country:US
Mailing Address - Phone:320-632-6621
Mailing Address - Fax:320-632-1829
Practice Address - Street 1:119 NE FIRST STREET
Practice Address - Street 2:STE 4
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345
Practice Address - Country:US
Practice Address - Phone:320-632-6621
Practice Address - Fax:320-632-1829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
85320EAOtherBLUE CROSS BLUE SHIELD
812989OtherUNITED OF CONCORDIA
1265OtherHEALTH PARTNERS