Healthcare Provider Details

I. General information

NPI: 1649964016
Provider Name (Legal Business Name): AMIRALI BEHDANI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12027 BUSINESS PARK BLVD N
CHAMPLIN MN
55316-4526
US

IV. Provider business mailing address

1325 UTICA AVE S APT 421
ST LOUIS PARK MN
55416-4596
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-7900
  • Fax:
Mailing address:
  • Phone: 980-349-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD14904
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: