Healthcare Provider Details

I. General information

NPI: 1144064700
Provider Name (Legal Business Name): MINNESOTA DENTAL PROFESSIONALS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5047 JASON AVE NE
ALBERTVILLE MN
55301-9688
US

IV. Provider business mailing address

5047 JASON AVE NE
ALBERTVILLE MN
55301-9688
US

V. Phone/Fax

Practice location:
  • Phone: 763-497-8165
  • Fax:
Mailing address:
  • Phone: 763-497-8165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CEMYIRA MCDOUGAL
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-764-8609