Provider Demographics
NPI:1215097134
Name:LEE PROHOFSKY DDS PA
Entity type:Organization
Organization Name:LEE PROHOFSKY DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:PROHOFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-428-2300
Mailing Address - Street 1:14000 NORTHDALE BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4663
Mailing Address - Country:US
Mailing Address - Phone:763-428-2300
Mailing Address - Fax:763-428-4031
Practice Address - Street 1:14000 NORTHDALE BLVD STE J
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4663
Practice Address - Country:US
Practice Address - Phone:763-428-2300
Practice Address - Fax:763-428-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN108431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty