Provider Demographics
NPI:1588794879
Name:MONTICELLO FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:MONTICELLO FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-295-3676
Mailing Address - Street 1:201 W. BROADWAY
Mailing Address - Street 2:P.O. BOX 969
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362
Mailing Address - Country:US
Mailing Address - Phone:763-295-3676
Mailing Address - Fax:
Practice Address - Street 1:201 W. BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362
Practice Address - Country:US
Practice Address - Phone:763-295-3676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty