Provider Demographics
NPI:1124456421
Name:EXCELSIOR DENTAL CARE
Entity type:Organization
Organization Name:EXCELSIOR DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT DESK MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-829-8863
Mailing Address - Street 1:7814 EXCELSIOR RD
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8427
Mailing Address - Country:US
Mailing Address - Phone:218-829-8863
Mailing Address - Fax:218-829-8863
Practice Address - Street 1:7814 EXCELSIOR RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8427
Practice Address - Country:US
Practice Address - Phone:218-829-8863
Practice Address - Fax:218-829-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9105305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service