Healthcare Provider Details

I. General information

NPI: 1447583778
Provider Name (Legal Business Name): LONE OAK FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W JOHNSON AVE SUITE 3
WARREN MN
56762-1118
US

IV. Provider business mailing address

205 W JOHNSON AVE SUITE 3
WARREN MN
56762-1118
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberD12024
License Number StateMN

VIII. Authorized Official

Name: TRAVIS HANEL
Title or Position: OWNER
Credential: DDS
Phone: 218-745-4601