NPIMap

Organization Active NPI

Mahtomedi Dental Clinic

  • General Practice Dentistry
  • Mahtomedi, MN
National Provider Identifier
1326284597
Registry record updated Dec 18, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
8217 Issued in MN
Legal business name
MAHTOMEDI DENTAL CLINIC
Practice address
814 Mahtomedi Ave
Mahtomedi, MN 55115-1730
Phone
(651) 426-0011
Fax
(651) 426-2075
NPI assigned
Dec 18, 2008
Last updated
Dec 18, 2008By the provider in NPPES
Organization subpart
Yes
Parent organization
MAHTOMEDI DENTAL CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 18, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Timothy A Bray
Title
Owner / Dentist
Phone
(651) 426-0011

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X 8217 MN Primary

Addresses

Primary practice location

814 Mahtomedi Ave
Mahtomedi, MN 55115-1730

Mailing address

814 Mahtomedi Ave
Mahtomedi, MN 55115-1730
Phone (651) 426-0011

Other identifiers 1

IdentifierTypeStateIssuer
982017500MedicaidMN

National Provider Directory

National Provider Directory
Tax ID family
Mahtomedi Dental Clinic3 organizations share this tax ID, including this one
Part of
Mahtomedi Dental Clinic

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1229558400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1229558400000",
    "number": "1326284597",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "814 MAHTOMEDI AVE",
            "city": "MAHTOMEDI",
            "state": "MN",
            "postal_code": "551151730",
            "telephone_number": "651-426-0011",
            "fax_number": "651-426-2075"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "814 MAHTOMEDI AVE",
            "city": "MAHTOMEDI",
            "state": "MN",
            "postal_code": "551151730",
            "telephone_number": "651-426-0011",
            "fax_number": "651-426-2075"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAHTOMEDI DENTAL CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MAHTOMEDI DENTAL CLINIC",
        "enumeration_date": "2008-12-18",
        "last_updated": "2008-12-18",
        "status": "A",
        "authorized_official_last_name": "BRAY",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER / DENTIST",
        "authorized_official_telephone_number": "651-426-0011",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "8217",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "982017500",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Mahtomedi, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.