MEDICARE: MINNESOTA DENTAL PROFESSIONALS, P.C.

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

General Provider Information

NPI Number	:	1679272488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA DENTAL PROFESSIONALS, P.C.

Provider Business Mailing Address
First Line	:	3220 COUNTY ROAD 10 STE A
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-3075
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3220 COUNTY ROAD 10 STE A
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-3075
Country	:	US
Telephone Number	:	763-561-6320
Fax Number	:

Authorized Official
Title or Position	:	CRED COORDINATOR
Name	:	HILLARY THULL
Credential	:
Telephone Number	:	217-540-8946

Provider Enumeration Date	:	03/01/2023
Last Update Date	:	05/08/2023

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