Healthcare Provider Details

I. General information

NPI: 1033206750
Provider Name (Legal Business Name): PINE RIDGE DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26273 2ND ST E SUITE A
ZIMMERMAN MN
55398
US

IV. Provider business mailing address

PO BOX 223 26273 2ND ST E SUITE A
ZIMMERMAN MN
55398
US

V. Phone/Fax

Practice location:
  • Phone: 763-856-5100
  • Fax: 763-856-0366
Mailing address:
  • Phone: 763-856-5100
  • Fax: 763-856-0366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER ANDRESEN NARR
Title or Position: DENTIST
Credential: DDS
Phone: 763-856-5100