MEDICARE: HOUSTON DENTAL CLINIC, PC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1790977114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSTON DENTAL CLINIC, PC

Provider Business Mailing Address
First Line	:	109 E MAPLE ST
Second Line	:
City	:	HOUSTON
State	:	MN
Zip	:	55943-8449
Country	:	US
Telephone Number	:	507-896-2202
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 E MAPLE ST
Second Line	:
City	:	HOUSTON
State	:	MN
Zip	:	55943-8449
Country	:	US
Telephone Number	:	507-896-2202
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RONALD ROBERT EVENSON
Credential	:	D.D.S.
Telephone Number	:	507-896-2202

Provider Enumeration Date	:	08/10/2007
Last Update Date	:	08/10/2007

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