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General NPI Number Information
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NPI Number | 1669949442
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Entity Type | Organization
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Legal Business Name | MISSISSIPPI HEADWATERS AREA DENTAL HEALTH CENTER, INC.
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Dates
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Enumeration Date | 10/30/2018
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Last Update Date | 10/30/2018
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Provider Practice Location Address
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Address Line | 132 3RD ST W
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City | HALSTAD
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State | MN
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Zip | 56548-4015
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Country | US
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Telephone | 218-456-2238
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Fax | 218-456-2248
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Provider Business Mailing Address
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Address Line | 1405 ANNE ST NW
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City | BEMIDJI
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State | MN
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Zip | 56601-5113
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Country | US
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Telephone | 218-444-9147
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | ERICA ANNE LUNDBERG
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Credential | MBA
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Telephone | 218-444-9147
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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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