NPIMap

Organization Active NPI

Eagle Lake Family Dentistry, P.a.

  • General Practice Dentistry
  • Eagle Lake, MN
National Provider Identifier
1528138948
Registry record updated Feb 9, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
EAGLE LAKE FAMILY DENTISTRY, P.A.
Practice address
104 Plainview Street
Box 97
Eagle Lake, MN 56024
Phone
(507) 257-3800
Fax
(507) 257-3456
NPI assigned
Nov 9, 2006
Last updated
Feb 9, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2016

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

Authorized official

Name
Dr. Bradley Allan Holmberg, BS, DDSNPI 1770653446
Title
President
Phone
(507) 257-3800

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X MN Primary

Addresses

Primary practice location

104 Plainview Street
Box 97
Eagle Lake, MN 56024

Mailing address

104 Plainview Street
Box 97
Eagle Lake, MN 56024
Phone (507) 257-3800

National Provider Directory

National Provider Directory
Tax ID family
Eagle Lake Family Dentistry PA2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1163030400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1454976000000",
    "number": "1528138948",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "104 PLAINVIEW STREET",
            "address_2": "BOX 97",
            "city": "EAGLE LAKE",
            "state": "MN",
            "postal_code": "56024",
            "telephone_number": "507-257-3800",
            "fax_number": "507-257-3456"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 PLAINVIEW STREET",
            "address_2": "BOX 97",
            "city": "EAGLE LAKE",
            "state": "MN",
            "postal_code": "56024",
            "telephone_number": "507-257-3800",
            "fax_number": "507-257-3456"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAGLE LAKE FAMILY DENTISTRY, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-09",
        "last_updated": "2016-02-09",
        "status": "A",
        "authorized_official_last_name": "HOLMBERG",
        "authorized_official_first_name": "BRADLEY",
        "authorized_official_middle_name": "ALLAN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "507-257-3800",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "BS, DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Eagle Lake, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 9, 2016; 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.