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NPI Code Detail

MEDICARE: JAIN DENTAL ST. LOUIS PARK, PLLC

MEDICARE: JAIN DENTAL ST. LOUIS PARK, PLLC
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
1261QD0000XDental Clinic/Center

General Provider Information

NPI Number : 1497373195
Entity Type Code : Organization
Provider Name (Legal Business Name) : JAIN DENTAL ST. LOUIS PARK, PLLC
Provider Business Mailing Address
First Line : 4600 EXCELSIOR BLVD
Second Line :
City : ST LOUIS PARK
State : MN
Zip : 55416-4938
Country : US
Telephone Number : 952-926-3392
Fax Number :
Provider Business Practice Location Address
First Line : 4600 EXCELSIOR BLVD
Second Line :
City : ST LOUIS PARK
State : MN
Zip : 55416-4938
Country : US
Telephone Number : 952-926-3392
Fax Number :
Authorized Official
Title or Position : GENERAL DENTIST
Name : DR. NICHOLAS BUSSA
Credential :
Telephone Number : 952-926-3392
Provider Enumeration Date : 07/08/2020
Last Update Date : 07/08/2020

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