Provider Demographics
NPI:1124150248
Name:MAIN STREET DENTAL
Entity type:Organization
Organization Name:MAIN STREET DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:JULIE
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-758-2376
Mailing Address - Street 1:301 MAIN ST E
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071-1803
Mailing Address - Country:US
Mailing Address - Phone:952-758-2376
Mailing Address - Fax:952-758-8708
Practice Address - Street 1:301 MAIN ST E
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-1803
Practice Address - Country:US
Practice Address - Phone:952-758-2376
Practice Address - Fax:952-758-8708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty