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General NPI Number Information
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NPI Number | 1104435585
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Entity Type | Organization
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Legal Business Name | FOUNTAIN LAKE FAMILY DENTAL
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Dates
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Enumeration Date | 07/30/2020
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Last Update Date | 07/30/2020
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Provider Practice Location Address
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Address Line | 146 W CLARK ST
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City | ALBERT LEA
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State | MN
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Zip | 56007-2546
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Country | US
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Telephone | 507-373-3323
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Fax | 507-373-4513
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Provider Business Mailing Address
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Address Line | 146 W CLARK ST
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City | ALBERT LEA
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State | MN
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Zip | 56007-2546
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Country | US
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Telephone | 507-373-3323
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | KARISA LEHMANN
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Credential |
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Telephone | 507-373-3323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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