Provider Demographics
NPI:1689952038
Name:EAGLE LAKE FAMILY DENTISTRY, PA
Entity type:Organization
Organization Name:EAGLE LAKE FAMILY DENTISTRY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:VOSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-257-3800
Mailing Address - Street 1:504 2ND AVE S
Mailing Address - Street 2:PO BOX 515
Mailing Address - City:SAINT JAMES
Mailing Address - State:MN
Mailing Address - Zip Code:56081-1737
Mailing Address - Country:US
Mailing Address - Phone:507-375-4611
Mailing Address - Fax:507-375-4989
Practice Address - Street 1:504 2ND AVE S
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MN
Practice Address - Zip Code:56081-1737
Practice Address - Country:US
Practice Address - Phone:507-375-4611
Practice Address - Fax:507-375-4989
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGLE LAKE FAMILY DENTISTRY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9088122300000X
MND11770122300000X
MND12980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1245529650OtherNPI
MN1528138948OtherNPI
MN1770653446OtherNPI
MN1649340050OtherNPI