Provider Demographics
NPI:1316118839
Name:PERSONA DENTAL P.C.
Entity type:Organization
Organization Name:PERSONA DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:CDA, RDA
Authorized Official - Phone:320-251-2972
Mailing Address - Street 1:2385 TROOP DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377
Mailing Address - Country:US
Mailing Address - Phone:320-251-2972
Mailing Address - Fax:320-255-5514
Practice Address - Street 1:2385 TROOP DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377
Practice Address - Country:US
Practice Address - Phone:320-251-2972
Practice Address - Fax:320-255-5514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10419122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty