Healthcare Provider Details

I. General information

NPI: 1699750802
Provider Name (Legal Business Name): MARK T ROSZKOWSKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E NICOLLET BLVD STE 205
BURNSVILLE MN
55337-6734
US

IV. Provider business mailing address

625 E NICOLLET BLVD STE 205
BURNSVILLE MN
55337-6734
US

V. Phone/Fax

Practice location:
  • Phone: 952-435-0310
  • Fax: 952-435-0311
Mailing address:
  • Phone: 952-435-0310
  • Fax: 952-435-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD10761
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: