Healthcare Provider Details

I. General information

NPI: 1902614167
Provider Name (Legal Business Name): MAPLE BROOK DENTAL CENTER OF MN LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 W BROADWAY AVE
BROOKLYN PARK MN
55445-2266
US

IV. Provider business mailing address

8401 W BROADWAY AVE
BROOKLYN PARK MN
55445-2266
US

V. Phone/Fax

Practice location:
  • Phone: 763-424-5313
  • Fax: 763-424-4503
Mailing address:
  • Phone: 763-424-5313
  • Fax: 763-424-4503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DANH LAM
Title or Position: OWNER DENTIST/PRESIDENT
Credential: DDS
Phone: 763-742-2773