Provider Demographics
NPI:1053834481
Name:MONDALE DENTAL LLC
Entity type:Organization
Organization Name:MONDALE DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MONDALE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-512-8500
Mailing Address - Street 1:10600 OLD COUNTY RD 15
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6205
Mailing Address - Country:US
Mailing Address - Phone:763-512-8500
Mailing Address - Fax:763-512-8592
Practice Address - Street 1:10600 OLD COUNTY RD 15
Practice Address - Street 2:SUITE 120
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6205
Practice Address - Country:US
Practice Address - Phone:763-512-8500
Practice Address - Fax:763-512-8592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN744487700Medicaid
MN744487700MNMedicaid