Provider Demographics
NPI:1154611200
Name:BELGRADE FAMILY DENTAL
Entity type:Organization
Organization Name:BELGRADE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGREW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-293-5380
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:PIERZ
Mailing Address - State:MN
Mailing Address - Zip Code:56364-0068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 BORGERDING AVE
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MN
Practice Address - Zip Code:56312-4533
Practice Address - Country:US
Practice Address - Phone:320-293-5380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN629412100Medicaid