Provider Demographics
NPI:1417191602
Name:ROSEVILLE DENTISTRY
Entity type:Organization
Organization Name:ROSEVILLE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:DULIN
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:651-631-3610
Mailing Address - Street 1:1912 LEXINGTON AVE. N.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-631-3610
Mailing Address - Fax:651-631-1626
Practice Address - Street 1:1912 LEXINGTON AVE N
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-6113
Practice Address - Country:US
Practice Address - Phone:651-631-3610
Practice Address - Fax:651-631-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty