Healthcare Provider Details

I. General information

NPI: 1841463072
Provider Name (Legal Business Name): NORTHERN LIGHTS FAMILY DENTISTRY,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 EMILY AVE. NW
WARROAD MN
56763
US

IV. Provider business mailing address

603 EMILY AVE. NW
WARROAD MN
56763
US

V. Phone/Fax

Practice location:
  • Phone: 218-386-2889
  • Fax:
Mailing address:
  • Phone: 218-386-2889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD11132
License Number StateMN

VIII. Authorized Official

Name: DR. CYNTHIA FAYE DROST-SANDY
Title or Position: DENTIST/PRESIDENT OF CORPORATION
Credential: DDS
Phone: 218-386-2889