Healthcare Provider Details

I. General information

NPI: 1619904208
Provider Name (Legal Business Name): HELLINA TEGAGNE DESSIE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5502 W BROADWAY AVE
CRYSTAL MN
55428-3508
US

IV. Provider business mailing address

1151 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-6324
US

V. Phone/Fax

Practice location:
  • Phone: 763-287-6500
  • Fax: 763-287-6544
Mailing address:
  • Phone: 612-706-4500
  • Fax: 612-781-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47888
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: