Basic Information
| Provider Information | |||||||||
| NPI: | 1861861619 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODLAND DENTAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 1ST ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553711604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633891373 | ||||||||
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| Practice Location | |||||||||
| Address1: | 510 1ST ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553711604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633891373 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2015 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | SNELGROVE | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | ROSS | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2186314431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 11459 | MN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.