MEDICARE: COMO PARK DENTISTRY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1194453951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMO PARK DENTISTRY PA

Provider Business Mailing Address
First Line	:	1132 LARPENTEUR AVE W
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55113-6317
Country	:	US
Telephone Number	:	507-272-5955
Fax Number	:

Provider Business Practice Location Address
First Line	:	1132 LARPENTEUR AVE W
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55113-6317
Country	:	US
Telephone Number	:	507-272-5955
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DERRIK HARTMAN
Credential	:	DDS
Telephone Number	:	507-272-5955

Provider Enumeration Date	:	08/10/2022
Last Update Date	:	08/10/2022

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Directions to “COMO PARK DENTISTRY PA ” Practice Location

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