Provider Demographics
NPI:1194801910
Name:MONTEVIDEO FAMILY DENTISTRY PA
Entity type:Organization
Organization Name:MONTEVIDEO FAMILY DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MONTEVIDEO FAMILY DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:ZENK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-269-6416
Mailing Address - Street 1:629 LEGION DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1729
Mailing Address - Country:US
Mailing Address - Phone:320-269-6416
Mailing Address - Fax:320-269-8136
Practice Address - Street 1:629 LEGION DR STE 2
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1729
Practice Address - Country:US
Practice Address - Phone:320-269-6416
Practice Address - Fax:320-269-8136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN657524200Medicaid