Healthcare Provider Details

I. General information

NPI: 1417101403
Provider Name (Legal Business Name): CLARISSA INGEBRITSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8960 SPRINGBROOK DR NW SUITE 150
COON RAPIDS MN
55433-5852
US

IV. Provider business mailing address

8960 SPRINGBROOK DR NW SUITE 150
COON RAPIDS MN
55433-5852
US

V. Phone/Fax

Practice location:
  • Phone: 763-784-7993
  • Fax: 763-785-8960
Mailing address:
  • Phone: 763-784-7993
  • Fax: 763-785-8960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH7639
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: