Healthcare Provider Details

I. General information

NPI: 1760449359
Provider Name (Legal Business Name): KENNETH J. ZUCKER D.D.S.,M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 NICOLS RD SUITE 202
EAGAN MN
55122-2306
US

IV. Provider business mailing address

4640 NICOLS RD SUITE 202
EAGAN MN
55122-2306
US

V. Phone/Fax

Practice location:
  • Phone: 651-994-1344
  • Fax: 651-994-1343
Mailing address:
  • Phone: 651-994-1344
  • Fax: 651-994-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number8621
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: