1073063103 NPI number — MINNESOTA DENTAL PROFESSIONALS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073063103 NPI number — MINNESOTA DENTAL PROFESSIONALS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA DENTAL PROFESSIONALS, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTAL ARTS OF MINNEAPOLIS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073063103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 NICOLLET MALL
Provider Second Line Business Mailing Address:
STE 425
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55402-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-332-7675
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 NICOLLET MALL
Provider Second Line Business Practice Location Address:
STE 425
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55402-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-332-7675
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TEUTSCH
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
217-540-8972

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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