Provider Demographics
NPI:1992821706
Name:ST. CLOUD TECHNICAL COLLEGE COMMUNITY DENTAL CLINIC
Entity type:Organization
Organization Name:ST. CLOUD TECHNICAL COLLEGE COMMUNITY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-308-5310
Mailing Address - Street 1:1540 NORTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1240
Mailing Address - Country:US
Mailing Address - Phone:320-308-5310
Mailing Address - Fax:320-308-5055
Practice Address - Street 1:1540 NORTHWAY DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1240
Practice Address - Country:US
Practice Address - Phone:320-308-5310
Practice Address - Fax:320-308-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty