Provider Demographics
NPI:1437978004
Name:WEST RANGE DENTAL PLLC
Entity type:Organization
Organization Name:WEST RANGE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:DONOVAN
Authorized Official - Last Name:HAMMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-348-4012
Mailing Address - Street 1:9 EASTRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-3124
Mailing Address - Country:US
Mailing Address - Phone:218-348-4012
Mailing Address - Fax:
Practice Address - Street 1:1043 E US HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3165
Practice Address - Country:US
Practice Address - Phone:218-326-2560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KYLE HAMMER DDS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental