Healthcare Provider Details

I. General information

NPI: 1497745400
Provider Name (Legal Business Name): WARROAD FAMILY DENTISTRY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 SOUTH STATE AVE
WARROAD MN
56763-0490
US

IV. Provider business mailing address

PO BOX 490
WARROAD MN
56763-0490
US

V. Phone/Fax

Practice location:
  • Phone: 218-386-1048
  • Fax: 218-386-1049
Mailing address:
  • Phone: 218-386-1048
  • Fax: 218-386-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9514
License Number StateMN

VIII. Authorized Official

Name: KATHY ANN THIELE
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 218-386-1048