| Organization Name: | MORA DENTAL CENTER |
| NPI Number: | 1700065687 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RENY CHACKO (DENTIST) |
| Mailing Address: | 547 Union St S Mora |
| State: | MN US |
| Postal Code: | 550511817 |
| Phone Number: | 3206792147 |
| Fax Number: | 3206792101 |
| NPI Enumeration Date: | 10/29/2007 |
| NPI Last Update Date: | 10/29/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 11844 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |