Basic Information
| Provider Information | |||||||||
| NPI: | 1598202319 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHITE BIRCH DENTAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 1ST ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553711604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633891373 | ||||||||
| FaxNumber: | 7633890538 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 1ST ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553711604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633891373 | ||||||||
| FaxNumber: | 7633890538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2017 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | LUND | ||||||||
| AuthorizedOfficialFirstName: | HEIDI | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7633891373 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D13243 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.