1508300252 NPI number — MINNESOTA PERIODONTAL ASSOCIATES, PA

Table of content: (NPI 1508300252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508300252 NPI number — MINNESOTA PERIODONTAL ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA PERIODONTAL ASSOCIATES, PA
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:
1508300252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4801 HWY 61 N.
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-429-2299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4801 HWY 61 N.
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110-2753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-429-2299
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PERIODONTIST
Authorized Official Telephone Number:
651-429-2299

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  D13190 , 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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