Provider Demographics
NPI:1558463869
Name:PILLAGER COUNTRY DENTAL LLC
Entity type:Organization
Organization Name:PILLAGER COUNTRY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-746-4555
Mailing Address - Street 1:727 BUCKSKIN AVE W.
Mailing Address - Street 2:
Mailing Address - City:PILLAGER
Mailing Address - State:MN
Mailing Address - Zip Code:56473
Mailing Address - Country:US
Mailing Address - Phone:218-746-4555
Mailing Address - Fax:218-746-4558
Practice Address - Street 1:727 BUCKSKIN AVE W
Practice Address - Street 2:
Practice Address - City:PILLAGER
Practice Address - State:MN
Practice Address - Zip Code:56473
Practice Address - Country:US
Practice Address - Phone:218-746-4555
Practice Address - Fax:218-746-4558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND87091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty