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NPI Code Detail

MEDICARE: LAKE SUPERIOR DENTAL ASSOCIATES

MEDICARE: LAKE SUPERIOR DENTAL ASSOCIATES
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
11223G0001XGeneral Practice Dentistry

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1820436OTHERMNUNITED CONCORDIA
27B014FOOTHERMNBCBS MN

General Provider Information

NPI Number : 1871672584
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKE SUPERIOR DENTAL ASSOCIATES
Provider Business Mailing Address
First Line : 1225 E 1ST ST
Second Line :
City : DULUTH
State : MN
Zip : 55805-2402
Country : US
Telephone Number : 218-728-6445
Fax Number : 218-724-7003
Provider Business Practice Location Address
First Line : 1225 E 1ST ST
Second Line :
City : DULUTH
State : MN
Zip : 55805-2402
Country : US
Telephone Number : 218-728-6445
Fax Number : 218-724-7003
Authorized Official
Title or Position : PARTNER
Name : DR. ROBERT G RYAN
Credential : DDS
Telephone Number : 218-728-6445
Provider Enumeration Date : 11/03/2006
Last Update Date : 10/30/2007

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1952488132 — DR. ROBERT G RYAN DDS
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1255410973 — DR. RODNEY A HELLER DDS, MS
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1891011748 — DR. ROSS ALLEN ANDERSON D.D.S.
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Directions to “LAKE SUPERIOR DENTAL ASSOCIATES ” Practice Location

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