Provider Demographics
NPI:1225786411
Name:PL DENTAL SC
Entity type:Organization
Organization Name:PL DENTAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:VINH
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-317-1168
Mailing Address - Street 1:9920 FOLEY BLVD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5216
Mailing Address - Country:US
Mailing Address - Phone:633-171-1667
Mailing Address - Fax:763-317-1167
Practice Address - Street 1:12628 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:ZIMMERMAN
Practice Address - State:MN
Practice Address - Zip Code:55398-9735
Practice Address - Country:US
Practice Address - Phone:833-217-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-16
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1790131791Medicaid