Organization
SOUTHERN HEIGHTS DENTAL GROUP PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KATE TONJUM (ADMINISTRATOR)
(507) 334-6433
Entity
Organization
Contact information
Practice address
1575 20TH STREET NORTHWEST, SUITE 102, FARIBAULT, MN 55021
(507) 334-6433
(507) 334-0044
Mailing address
1575 20TH STREET NORTHWEST, SUITE 102, FARIBAULT, MN 55021
(507) 334-6433
(507) 334-0044
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
D10323
MN
1223G0001X
General Practice Dentistry
D11400
MN
1223G0001X
General Practice Dentistry
D11586
MN
1223G0001X
General Practice Dentistry
D11631
MN
1223G0001X
General Practice Dentistry
Primary
D7800
MN
1223G0001X
General Practice Dentistry
D8742
MN
1223G0001X
General Practice Dentistry
D9884
MN
261QD0000X
Dental Clinic/Center
D13095
MN
261QD0000X
Dental Clinic/Center
D7800
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
148427300
—
MN
05
—
284735300
—
MN
05
—
325522100
—
MN
05
—
440217100
—
MN
05
—
443655000
—
MN
05
—
550722700
—
MN
05
—
607320400
—
MN
05
—
849698600
—
MN
05
—
856415900
—
MN
Enumeration date
02/02/2007
Last updated
08/06/2020
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