Healthcare Provider Details

I. General information

NPI: 1811033061
Provider Name (Legal Business Name): WILLMAR DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 TECHNOLOGY DR NE
WILLMAR MN
56201
US

IV. Provider business mailing address

PO BOX 64979
SAINT PAUL MN
55164-0979
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA O ALABI
Title or Position: HUMAN SERVICE MANAGER
Credential:
Phone: 651-478-8002