Healthcare Provider Details

I. General information

NPI: 1952898660
Provider Name (Legal Business Name): FOREVER SMILES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 W MAIN ST
ARLINGTON MN
55307-2133
US

IV. Provider business mailing address

1015 GREELEY AVE N
GLENCOE MN
55336-2129
US

V. Phone/Fax

Practice location:
  • Phone: 507-964-2748
  • Fax: 507-964-2707
Mailing address:
  • Phone: 320-864-3129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD12456
License Number StateMN

VIII. Authorized Official

Name: JESSICA BAUER
Title or Position: OFFICE MANAGER
Credential:
Phone: 320-864-3129