Provider Demographics
NPI:1386999290
Name:NORTHWEST DENTAL GROUP
Entity type:Organization
Organization Name:NORTHWEST DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-289-3921
Mailing Address - Street 1:2056 SUPERIOR DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-5024
Mailing Address - Country:US
Mailing Address - Phone:507-289-3921
Mailing Address - Fax:
Practice Address - Street 1:2056 SUPERIOR DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-5024
Practice Address - Country:US
Practice Address - Phone:507-289-3921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty