Healthcare Provider Details

I. General information

NPI: 1285206318
Provider Name (Legal Business Name): LANDON MICHAEL KUDRNA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 07/16/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12170 ABERDEEN ST NE
BLAINE MN
55449-4716
US

IV. Provider business mailing address

12170 ABERDEEN ST NE
BLAINE MN
55449-4716
US

V. Phone/Fax

Practice location:
  • Phone: 637-577-0007
  • Fax: 763-757-3328
Mailing address:
  • Phone: 763-757-7000
  • Fax: 763-757-3328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3746
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: