Provider Demographics
NPI:1992943336
Name:ELY FAMILY DENTISTRY
Entity type:Organization
Organization Name:ELY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BEERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-365-3145
Mailing Address - Street 1:40 N 1ST AVE E
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731
Mailing Address - Country:US
Mailing Address - Phone:218-365-3145
Mailing Address - Fax:
Practice Address - Street 1:40 N 1ST AVE E
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731
Practice Address - Country:US
Practice Address - Phone:218-365-3145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty