Healthcare Provider Details

I. General information

NPI: 1588261812
Provider Name (Legal Business Name): NEW LONDON FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ASH ST SE
NEW LONDON MN
56273
US

IV. Provider business mailing address

15 ASH ST SE
NEW LONDON MN
56273
US

V. Phone/Fax

Practice location:
  • Phone: 320-354-2207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ANDREA MCGREW
Title or Position: CFO/DDS
Credential:
Phone: 320-293-4095