Provider Demographics
NPI:1992075287
Name:UNIVERSITY OF MINNESOTA PEDIATRIC DENTAL CLINIC
Entity type:Organization
Organization Name:UNIVERSITY OF MINNESOTA PEDIATRIC DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-884-0802
Mailing Address - Street 1:701 25TH AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1513
Mailing Address - Country:US
Mailing Address - Phone:651-659-4900
Mailing Address - Fax:651-659-4901
Practice Address - Street 1:701 25TH AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1513
Practice Address - Country:US
Practice Address - Phone:651-659-4900
Practice Address - Fax:651-659-4901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UMPHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-04
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty