Healthcare Provider Details

I. General information

NPI: 1811041429
Provider Name (Legal Business Name): MARK R. KAUPPI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6437 BROOKLYN BLVD
BROOKLYN CENTER MN
55429-2174
US

IV. Provider business mailing address

14605 GLAZIER AVE
APPLE VALLEY MN
55124-7545
US

V. Phone/Fax

Practice location:
  • Phone: 763-535-6010
  • Fax:
Mailing address:
  • Phone: 952-432-1103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11466
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: