MEDICARE: LONE OAK FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	D12024	MN

General Provider Information

NPI Number	:	1447583778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONE OAK FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	205 W JOHNSON AVE
Second Line	:	SUITE 3
City	:	WARREN
State	:	MN
Zip	:	56762-1118
Country	:	US
Telephone Number	:	218-745-4601
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 W JOHNSON AVE
Second Line	:	SUITE 3
City	:	WARREN
State	:	MN
Zip	:	56762-1118
Country	:	US
Telephone Number	:	218-745-4601
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TRAVIS HANEL
Credential	:	DDS
Telephone Number	:	218-745-4601

Provider Enumeration Date	:	09/18/2009
Last Update Date	:	09/18/2009

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Directions to “LONE OAK FAMILY DENTISTRY ” Practice Location

Language	Start Address	Practice Location

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