Healthcare Provider Details

I. General information

NPI: 1144583527
Provider Name (Legal Business Name): GREAT RIVER ENDODONTICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 19TH AVE SW
WILLMAR MN
56201-5006
US

IV. Provider business mailing address

622 ROOSEVELT RD STE 180
SAINT CLOUD MN
56301-6361
US

V. Phone/Fax

Practice location:
  • Phone: 320-259-5078
  • Fax: 320-259-5078
Mailing address:
  • Phone: 320-259-5078
  • Fax: 320-259-1484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number11880
License Number StateMN

VIII. Authorized Official

Name: DR. THOMAS ANDREW KARN
Title or Position: OWNER/PRESIDENT
Credential: DMD
Phone: 320-259-5078