Provider Demographics
NPI:1528138948
Name:EAGLE LAKE FAMILY DENTISTRY, P.A.
Entity type:Organization
Organization Name:EAGLE LAKE FAMILY DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:HOLMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:BS, DDS
Authorized Official - Phone:507-257-3800
Mailing Address - Street 1:104 PLAINVIEW STREET
Mailing Address - Street 2:BOX 97
Mailing Address - City:EAGLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56024
Mailing Address - Country:US
Mailing Address - Phone:507-257-3800
Mailing Address - Fax:507-257-3456
Practice Address - Street 1:104 PLAINVIEW STREET
Practice Address - Street 2:BOX 97
Practice Address - City:EAGLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:56024
Practice Address - Country:US
Practice Address - Phone:507-257-3800
Practice Address - Fax:507-257-3456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty