Provider Demographics
NPI:1295907202
Name:SUMMIT DENTAL P.A.
Entity type:Organization
Organization Name:SUMMIT DENTAL P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MARKSBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-757-4170
Mailing Address - Street 1:10756 BUTTERNUT ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-4448
Mailing Address - Country:US
Mailing Address - Phone:763-757-4170
Mailing Address - Fax:763-757-7940
Practice Address - Street 1:10756 BUTTERNUT ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-4448
Practice Address - Country:US
Practice Address - Phone:763-757-4170
Practice Address - Fax:763-757-7940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND117891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty