MEDICARE: DERRIK HARTMAN

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	D13222	MN

General Provider Information

NPI Number	:	1659711299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRIK HARTMAN

Provider Business Mailing Address
First Line	:	7512 10TH ST SE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55904-8661
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	:	651-489-0641
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2013
Last Update Date	:	12/07/2020

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Directions to “ DERRIK HARTMAN ” Practice Location

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