Healthcare Provider Details

I. General information

NPI: 1619382876
Provider Name (Legal Business Name): DENTAL SPECIALISTS OF MINNESOTA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12180 BUSINESS PARK BLVD N
CHAMPLIN MN
55316-4525
US

IV. Provider business mailing address

2200 COUNTY ROAD C W STE 2210
ROSEVILLE MN
55113-2551
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-5206
  • Fax: 763-421-8320
Mailing address:
  • Phone: 651-633-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ALAN LAW
Title or Position: PRESIDENT
Credential:
Phone: 651-633-0500