MEDICARE: ADT DENTAL, LTD.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46092 DE	OTHER	MN	BLUE CROSS BLUE SHIELD
2	013454	OTHER	MN	DORAL DENTAL
3	1727	OTHER	MN	HEALTH PARTNERS
4	978483	OTHER	MN	UNITED CONCORDIA

General Provider Information

NPI Number	:	1548282585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADT DENTAL, LTD.

Provider Business Mailing Address
First Line	:	2232 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2737
Country	:	US
Telephone Number	:	612-377-6108
Fax Number	:	612-374-1820

Provider Business Practice Location Address
First Line	:	2232 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2737
Country	:	US
Telephone Number	:	612-377-6108
Fax Number	:	612-374-1820

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	MS. SUSAN ZECCO
Credential	:
Telephone Number	:	612-377-6108

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	08/22/2020

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Directions to “ADT DENTAL, LTD. ” Practice Location

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