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General NPI Number Information
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NPI Number | 1144760158
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Entity Type | Organization
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Legal Business Name | MORA DENTAL CENTER LLC
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Dates
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Enumeration Date | 02/24/2017
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Last Update Date | 02/24/2017
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Provider Practice Location Address
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Address Line | 547 UNION ST S
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City | MORA
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State | MN
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Zip | 55051-1875
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Country | US
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Telephone | 320-679-2147
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Fax | 320-679-2101
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Provider Business Mailing Address
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Address Line | 547 UNION ST S
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City | MORA
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State | MN
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Zip | 55051
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Country | US
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Telephone | 320-679-2147
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Fax | 320-679-2101
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JENNIFER VANDERPOEL
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Credential | DDS
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Telephone | 320-679-2147
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D11774
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License Number State | MN
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