Healthcare Provider Details

I. General information

NPI: 1063768687
Provider Name (Legal Business Name): BLAINE DENTAL LLC DBA PRO DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10210 BALTIMORE ST NE SUITE 100
BLAINE MN
55449-6049
US

IV. Provider business mailing address

10210 BALTIMORE ST NE SUITE 100
BLAINE MN
55449-6049
US

V. Phone/Fax

Practice location:
  • Phone: 763-231-2050
  • Fax: 763-231-2052
Mailing address:
  • Phone: 763-231-2050
  • Fax: 763-231-2052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. ARIF NAZIR
Title or Position: BDS
Credential: BDS
Phone: 763-231-2050