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General NPI Number Information
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NPI Number | 1053739698
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Entity Type | Organization
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Legal Business Name | LONE OAK FAMILY DENTISTRY
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Dates
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Enumeration Date | 04/01/2014
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Last Update Date | 04/01/2014
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Provider Practice Location Address
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Address Line | 205 W JOHNSON AVE STE. 3
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City | WARREN
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State | MN
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Zip | 56762-1118
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Country | US
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Telephone | 218-745-4601
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Fax | 218-745-4600
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Provider Business Mailing Address
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Address Line | 205 W JOHNSON AVE STE. 3
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City | WARREN
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State | MN
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Zip | 56762-1118
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Country | US
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Telephone | 218-745-4601
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Fax | 218-745-4600
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Authorized Official
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Title or Position | DENTIST
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Name | DR. TRAVIS AMMEN HANEL
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Credential |
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Telephone | 218-745-4601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D12024
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License Number State | MN
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