Healthcare Provider Details

I. General information

NPI: 1053739698
Provider Name (Legal Business Name): LONE OAK FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W JOHNSON AVE STE. 3
WARREN MN
56762-1118
US

IV. Provider business mailing address

205 W JOHNSON AVE STE. 3
WARREN MN
56762-1118
US

V. Phone/Fax

Practice location:
  • Phone: 218-745-4601
  • Fax: 218-745-4600
Mailing address:
  • Phone: 218-745-4601
  • Fax: 218-745-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12024
License Number StateMN

VIII. Authorized Official

Name: DR. TRAVIS AMMEN HANEL
Title or Position: DENTIST
Credential:
Phone: 218-745-4601