Healthcare Provider Details

I. General information

NPI: 1770672958
Provider Name (Legal Business Name): FRIENDLY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 MCMILLAN ST
WORTHINGTON MN
56187-1646
US

IV. Provider business mailing address

1316 MCMILLAN ST
WORTHINGTON MN
56187-1646
US

V. Phone/Fax

Practice location:
  • Phone: 507-376-5525
  • Fax: 507-376-3796
Mailing address:
  • Phone: 507-376-5525
  • Fax: 507-376-3796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number10185
License Number StateMN

VIII. Authorized Official

Name: DR. JERRY LEE JOHNSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 507-376-5525