MEDICARE: DR. LISA ANN EDSTROM DDS

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	D12681	MN

General Provider Information

NPI Number	:	1922235027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA ANN EDSTROM DDS

Provider Business Mailing Address
First Line	:	3436 DENMARK AVE
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-1088
Country	:	US
Telephone Number	:	651-452-4455
Fax Number	:

Provider Business Practice Location Address
First Line	:	3436 DENMARK AVE
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-1088
Country	:	US
Telephone Number	:	651-452-4455
Fax Number	:

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

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	09/30/2020

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