MEDICARE: NORTHERN LAKES DENTAL - RIVERFRONT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1013554310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN LAKES DENTAL - RIVERFRONT, LLC

Provider Business Mailing Address
First Line	:	1108 WESTERN AVE
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-4808
Country	:	US
Telephone Number	:	218-736-4000
Fax Number	:	218-736-0766

Provider Business Practice Location Address
First Line	:	124 E LINCOLN AVE
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-2217
Country	:	US
Telephone Number	:	218-736-5627
Fax Number	:	218-736-6955

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	CATIE SUE BAGLO
Credential	:
Telephone Number	:	218-736-4000

Provider Enumeration Date	:	12/05/2019
Last Update Date	:	12/05/2019

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