Provider Demographics
NPI:1053591255
Name:ADVANCE FAMILY DENTAL
Entity type:Organization
Organization Name:ADVANCE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIDL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-482-1122
Mailing Address - Street 1:925 COUNTY ROAD E E
Mailing Address - Street 2:SUITE 185
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-7179
Mailing Address - Country:US
Mailing Address - Phone:651-482-1122
Mailing Address - Fax:651-766-2557
Practice Address - Street 1:925 COUNTY ROAD E E
Practice Address - Street 2:SUITE 185
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-7179
Practice Address - Country:US
Practice Address - Phone:651-482-1122
Practice Address - Fax:651-766-2557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9142261QD0000X
MN12387261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental