Healthcare Provider Details

I. General information

NPI: 1205204674
Provider Name (Legal Business Name): WILLMAR FAMILY DENTISTRY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 1ST ST S
WILLMAR MN
56201-3510
US

IV. Provider business mailing address

1016 1ST ST S
WILLMAR MN
56201-3510
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-2010
  • Fax: 320-235-7133
Mailing address:
  • Phone: 320-235-2010
  • Fax: 320-235-7133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9800
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT54
License Number StateMN

VIII. Authorized Official

Name: DR. PETER JORGENSON
Title or Position: DENTIST
Credential: D.D.S.
Phone: 320-235-2010