MEDICARE: MSP DENTISTRY, INC.

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	305R00000X	Preferred Provider Organization	D12034	MN

General Provider Information

NPI Number	:	1558719922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MSP DENTISTRY, INC.

Provider Business Mailing Address
First Line	:	12027 BUSINESS PARK BLVD N
Second Line	:
City	:	CHAMPLIN
State	:	MN
Zip	:	55316-4526
Country	:	US
Telephone Number	:	763-421-7900
Fax Number	:	763-421-7916

Provider Business Practice Location Address
First Line	:	12027 BUSINESS PARK BLVD N
Second Line	:
City	:	CHAMPLIN
State	:	MN
Zip	:	55316-4526
Country	:	US
Telephone Number	:	763-421-7900
Fax Number	:	763-421-7916

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. MAJID FEHRESTI
Credential	:	D.D.S.
Telephone Number	:	763-421-7900

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	05/26/2016

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