Provider Demographics
NPI:1841515582
Name:HERZING UNIVERSITY DENTAL HYGIENE CLINIC
Entity type:Organization
Organization Name:HERZING UNIVERSITY DENTAL HYGIENE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAMPUS PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SLAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-535-3000
Mailing Address - Street 1:5700 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3568
Mailing Address - Country:US
Mailing Address - Phone:763-535-3000
Mailing Address - Fax:763-535-9205
Practice Address - Street 1:5700 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3568
Practice Address - Country:US
Practice Address - Phone:763-535-3000
Practice Address - Fax:763-535-9205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERZING, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty