Provider Demographics
NPI:1194887521
Name:ROGER G. ETTEL D.D.S. & ASSOCIATES, PA
Entity type:Organization
Organization Name:ROGER G. ETTEL D.D.S. & ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:ETTEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:651-429-2299
Mailing Address - Street 1:4801 HIGHWAY 61 N # SU-300
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2737
Mailing Address - Country:US
Mailing Address - Phone:651-429-2299
Mailing Address - Fax:651-429-6630
Practice Address - Street 1:4801 HIGHWAY 61 N # SU-300
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2737
Practice Address - Country:US
Practice Address - Phone:651-429-2299
Practice Address - Fax:651-429-6630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223PO300X1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty