Provider Demographics
NPI:1174872949
Name:SHAMBLOTT FAMILY DENTISTRY
Entity type:Organization
Organization Name:SHAMBLOTT FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTINA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:VERHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-935-5599
Mailing Address - Street 1:33 10TH AVE S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-1303
Mailing Address - Country:US
Mailing Address - Phone:952-935-5599
Mailing Address - Fax:952-935-7842
Practice Address - Street 1:33 10TH AVE S
Practice Address - Street 2:SUITE 250
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-1303
Practice Address - Country:US
Practice Address - Phone:952-935-5599
Practice Address - Fax:952-935-7842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty