Healthcare Provider Details

I. General information

NPI: 1437287679
Provider Name (Legal Business Name): MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 AMERICA AVE NW STE 340 ATTENTION MARY MARCHELL
BEMIDJI MN
56601-3871
US

IV. Provider business mailing address

616 AMERICA AVE NW STE 340 ATTENTION MARY MARCHELL
BEMIDJI MN
56601-3871
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-8119
  • Fax:
Mailing address:
  • Phone: 218-333-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number StateMN

VIII. Authorized Official

Name: MS. MARY MARCHEL
Title or Position: SECRETARY, TREASURER
Credential:
Phone: 218-333-8119