Basic Information
| Provider Information | |||||||||
| NPI: | 1588794879 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTICELLO FAMILY DENTISTRY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W. BROADWAY | ||||||||
| Address2: | P.O. BOX 969 | ||||||||
| City: | MONTICELLO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632953676 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 W. BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632953676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLOCK | ||||||||
| AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7632953676 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D12145 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.