# MONDALE DENTAL LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Roger Mondale, DDS, Roger Mondale DDS
- **Organization subpart:** No

## Provider details

- **NPI number:** 1053834481
- **Authorized official:** MR. BRIAN PATRICK MONDALE D.D.S. (OWNER SOLE MEMBER)
- **Authorized official phone:** (763) 512-8500

## Contact information

- **Practice address:** 10600 OLD COUNTY RD 15, SUITE 120, PLYMOUTH, MN 55441-6205
- **Practice address phone:** (763) 512-8500
- **Practice address fax:** (763) 512-8592
- **Mailing address:** 10600 OLD COUNTY RD 15, SUITE 120, PLYMOUTH, MN 55441-6205
- **Mailing address phone:** (763) 512-8500
- **Mailing address fax:** (763) 512-8592

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |
| 261QD0000X | Dental Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 07/18/2017
- **Last updated:** 07/30/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 744487700 | — | MN |
| 05 | — | 744487700MN | — | MN |