Provider Demographics
NPI:1386335602
Name:3RD STREET DENTAL LLC
Entity type:Organization
Organization Name:3RD STREET DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISRAEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-710-0666
Mailing Address - Street 1:3RD STREET DENTAL LLC
Mailing Address - Street 2:PO BOX 1153
Mailing Address - City:TRACY
Mailing Address - State:MN
Mailing Address - Zip Code:56175
Mailing Address - Country:US
Mailing Address - Phone:646-710-0666
Mailing Address - Fax:
Practice Address - Street 1:212 3RD ST STE 5
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:MN
Practice Address - Zip Code:56175-1267
Practice Address - Country:US
Practice Address - Phone:507-626-8826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty