Provider Demographics
NPI:1215083183
Name:NORTHWOODS DENTAL
Entity type:Organization
Organization Name:NORTHWOODS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-557-0911
Mailing Address - Street 1:15600 36TH AVE N
Mailing Address - Street 2:SUITE 270
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3369
Mailing Address - Country:US
Mailing Address - Phone:763-557-0911
Mailing Address - Fax:763-557-5157
Practice Address - Street 1:15600 36TH AVE N
Practice Address - Street 2:SUITE 270
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3369
Practice Address - Country:US
Practice Address - Phone:763-557-0911
Practice Address - Fax:763-557-5157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty