MEDICARE: RIVER BLUFF DENTAL, P.A.

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	122300000X	Dentist	D10102	MN

General Provider Information

NPI Number	:	1609098458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER BLUFF DENTAL, P.A.

Provider Business Mailing Address
First Line	:	10851 RHODE ISLAND AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55438-2393
Country	:	US
Telephone Number	:	952-884-5361
Fax Number	:	952-946-9533

Provider Business Practice Location Address
First Line	:	10851 RHODE ISLAND AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55438-2393
Country	:	US
Telephone Number	:	952-884-5361
Fax Number	:	952-946-9533

Authorized Official
Title or Position	:	DENTIST & OWNER
Name	:	DR. WALTER PALMER
Credential	:
Telephone Number	:	952-884-5361

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/22/2020

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