Provider Demographics
NPI:1699483941
Name:EVERGREEN DENTAL PLLC
Entity type:Organization
Organization Name:EVERGREEN DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-298-5816
Mailing Address - Street 1:14347 GOLF VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-3004
Mailing Address - Country:US
Mailing Address - Phone:952-937-7677
Mailing Address - Fax:
Practice Address - Street 1:7890 MITCHELL RD
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-2219
Practice Address - Country:US
Practice Address - Phone:952-937-7677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1003256876OtherNPI
MN1144287962OtherNPI