MEDICARE: BLOOMINGTON LAKE DENTAL CLINIC PA

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	D11528	MN

General Provider Information

NPI Number	:	1861587842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMINGTON LAKE DENTAL CLINIC PA

Provider Business Mailing Address
First Line	:	3042 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1716
Country	:	US
Telephone Number	:	612-729-2393
Fax Number	:	612-729-2395

Provider Business Practice Location Address
First Line	:	3042 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1716
Country	:	US
Telephone Number	:	612-729-2393
Fax Number	:	612-729-2395

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. SAUNDRA ANN ROHRER
Credential	:
Telephone Number	:	612-729-2393

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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