Healthcare Provider Details

I. General information

NPI: 1730738295
Provider Name (Legal Business Name): CHAIN OF LAKES DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2019
Last Update Date: 09/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MAIN ST E
RICHMOND MN
56368-8238
US

IV. Provider business mailing address

111 7TH AVE N
SARTELL MN
56377-1858
US

V. Phone/Fax

Practice location:
  • Phone: 320-597-2453
  • Fax:
Mailing address:
  • Phone: 612-805-9134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAWN MICHAEL SPODEN
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 320-597-2453