Healthcare Provider Details

I. General information

NPI: 1053831941
Provider Name (Legal Business Name): CHANHASSEN FAMILY DENTISTRY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8116 MALLORY CT
CHANHASSEN MN
55317-8586
US

IV. Provider business mailing address

8116 MALLORY CT
CHANHASSEN MN
55317-8586
US

V. Phone/Fax

Practice location:
  • Phone: 953-443-3368
  • Fax: 952-443-3330
Mailing address:
  • Phone: 953-443-3368
  • Fax: 952-443-3330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL LEONARD
Title or Position: OWNER
Credential: DDS
Phone: 952-443-3368