1265097653 NPI number — THE DENTAL SPECIALIST OF MINNESOTA, PLLC

Table of content: (NPI 1265097653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265097653 NPI number — THE DENTAL SPECIALIST OF MINNESOTA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE DENTAL SPECIALIST OF MINNESOTA, 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:
1265097653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 COUNTY ROAD C W STE 2210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113-2551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13961 60TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55082-1053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-760-3681
Provider Business Practice Location Address Fax Number:
651-760-3683
Provider Enumeration Date:
05/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HESSE
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
651-746-2815

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com