Provider Demographics
NPI:1427455062
Name:SHETEK DENTAL CARE PA
Entity type:Organization
Organization Name:SHETEK DENTAL CARE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NARLA
Authorized Official - Middle Name:NORINE
Authorized Official - Last Name:HULSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:CDA, RDA
Authorized Official - Phone:507-836-1000
Mailing Address - Street 1:106 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:FULDA
Mailing Address - State:MN
Mailing Address - Zip Code:56131-1101
Mailing Address - Country:US
Mailing Address - Phone:507-425-2276
Mailing Address - Fax:507-425-2769
Practice Address - Street 1:106 2ND ST NW
Practice Address - Street 2:
Practice Address - City:FULDA
Practice Address - State:MN
Practice Address - Zip Code:56131
Practice Address - Country:US
Practice Address - Phone:507-425-2276
Practice Address - Fax:507-425-2769
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHETEK DENTAL CARE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12229122300000X
MN8209122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1629187364Medicaid
MN1881639201Medicaid