1134547730 NPI number — SOUTHDALE PERIODONTICS, PLLC

Table of content: (NPI 1134547730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134547730 NPI number — SOUTHDALE PERIODONTICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHDALE PERIODONTICS, PLLC
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:
Provider Other Organization Name Type Code:
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:
1134547730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6545 FRANCE AVE S
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-2131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-922-6949
Provider Business Mailing Address Fax Number:
952-922-9287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6545 FRANCE AVE S
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-2131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-922-6949
Provider Business Practice Location Address Fax Number:
952-922-9287
Provider Enumeration Date:
04/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DYLLA
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
952-922-6949

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  D12016 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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