MEDICARE: DEBORRAH JANE NORDBLOM D.D.S.

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	D10101	MN
2	1223G0001X	General Practice Dentistry	10101	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000724372	OTHER	MN	UNITED CONCORDIA

General Provider Information

NPI Number	:	1821155573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORRAH JANE NORDBLOM D.D.S.

Provider Business Mailing Address
First Line	:	14990 GLAZIER AVE
Second Line	:
City	:	APPLE VALLEY
State	:	MN
Zip	:	55124-7818
Country	:	US
Telephone Number	:	952-431-5114
Fax Number	:	952-431-3576

Provider Business Practice Location Address
First Line	:	14990 GLAZIER AVE
Second Line	:
City	:	APPLE VALLEY
State	:	MN
Zip	:	55124-7818
Country	:	US
Telephone Number	:	952-431-5114
Fax Number	:	952-431-3576

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	08/05/2019

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