1396095048 NPI number — DENTAL SPECIALISTS OF MINNESOTA, PLLC

Table of content: (NPI 1396095048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396095048 NPI number — DENTAL SPECIALISTS OF MINNESOTA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL SPECIALISTS 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:
6
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:
1396095048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
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
Provider Second Line Business Mailing Address:
SUITE 2210
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113-2550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-633-0500
Provider Business Mailing Address Fax Number:
651-636-6894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3360 NORTHDALE BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55448-1825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-201-6962
Provider Business Practice Location Address Fax Number:
952-201-1183
Provider Enumeration Date:
09/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LAW
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
651-633-0500

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)





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