Healthcare Provider Details

I. General information

NPI: 1992847453
Provider Name (Legal Business Name): RAINTREE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13551 BALSAM LN
DAYTON MN
55327
US

IV. Provider business mailing address

13551 BALSAM LN
DAYTON MN
55327
US

V. Phone/Fax

Practice location:
  • Phone: 763-422-1714
  • Fax: 763-712-5754
Mailing address:
  • Phone: 763-422-1714
  • Fax: 763-712-5754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10574
License Number StateMN

VIII. Authorized Official

Name: DR. PATRICK ANTHONY AYDT
Title or Position: OWNER
Credential: DDS
Phone: 763-422-1714