Provider Demographics
NPI:1053739698
Name:LONE OAK FAMILY DENTISTRY
Entity type:Organization
Organization Name:LONE OAK FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:AMMEN
Authorized Official - Last Name:HANEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-745-4601
Mailing Address - Street 1:205 W JOHNSON AVE
Mailing Address - Street 2:STE. 3
Mailing Address - City:WARREN
Mailing Address - State:MN
Mailing Address - Zip Code:56762-1118
Mailing Address - Country:US
Mailing Address - Phone:218-745-4601
Mailing Address - Fax:218-745-4600
Practice Address - Street 1:205 W JOHNSON AVE
Practice Address - Street 2:STE. 3
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-1118
Practice Address - Country:US
Practice Address - Phone:218-745-4601
Practice Address - Fax:218-745-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN473990600Medicaid