Healthcare Provider Details

I. General information

NPI: 1457571952
Provider Name (Legal Business Name): DISTINCTIVE DENTAL SERVICES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 MAIN AVE W
WINSTED MN
55395-7873
US

IV. Provider business mailing address

131 MAIN AVENUE WEST BOX 599
WINSTED MN
55395-0599
US

V. Phone/Fax

Practice location:
  • Phone: 320-485-4344
  • Fax: 320-485-4734
Mailing address:
  • Phone: 320-485-4344
  • Fax: 320-485-4734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MICHAEL JOHN THOENNES
Title or Position: CEO
Credential: DDS
Phone: 320-485-4344