Provider Demographics
NPI:1316911415
Name:MAIN STREET DENTAL CLINIC OF NEW RICHLAND PLLP
Entity type:Organization
Organization Name:MAIN STREET DENTAL CLINIC OF NEW RICHLAND PLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-583-2141
Mailing Address - Street 1:132 NORTH BROADWAY
Mailing Address - Street 2:PO BOX 278
Mailing Address - City:NEW RICHLAND
Mailing Address - State:MN
Mailing Address - Zip Code:56072
Mailing Address - Country:US
Mailing Address - Phone:507-463-0502
Mailing Address - Fax:507-463-0769
Practice Address - Street 1:132 NORTH BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW RICHLAND
Practice Address - State:MN
Practice Address - Zip Code:56072
Practice Address - Country:US
Practice Address - Phone:507-463-0502
Practice Address - Fax:507-463-0769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN80692531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty