Healthcare Provider Details

I. General information

NPI: 1184637753
Provider Name (Legal Business Name): MARK J JUETTEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31378 CO 24 BLVD
CANNON FALLS MN
55009
US

IV. Provider business mailing address

PO BOX 15
CANNON FALLS MN
55009
US

V. Phone/Fax

Practice location:
  • Phone: 507-263-3965
  • Fax: 507-263-9485
Mailing address:
  • Phone: 507-263-3965
  • Fax: 507-263-9485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberMN 7819
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: