Provider Demographics
NPI:1275362329
Name:HER AND MAN TOWN DENTAL PLLC
Entity type:Organization
Organization Name:HER AND MAN TOWN DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKITALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-722-2428
Mailing Address - Street 1:4135 RICHARD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2979
Mailing Address - Country:US
Mailing Address - Phone:218-722-2428
Mailing Address - Fax:218-722-0142
Practice Address - Street 1:4135 RICHARD AVE STE 103
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-2979
Practice Address - Country:US
Practice Address - Phone:218-722-2428
Practice Address - Fax:218-722-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental