Healthcare Provider Details

I. General information

NPI: 1073727293
Provider Name (Legal Business Name): FLORENA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8785 COLUMBINE RD
EDEN PRAIRIE MN
55344-6695
US

IV. Provider business mailing address

8785 COLUMBINE RD
EDEN PRAIRIE MN
55344-6695
US

V. Phone/Fax

Practice location:
  • Phone: 952-941-7393
  • Fax: 952-941-2162
Mailing address:
  • Phone: 952-941-7393
  • Fax: 952-941-2162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD11618
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD11618
License Number StateMN

VIII. Authorized Official

Name: R. ANGELA WANDERA
Title or Position: DR. ANGELA WANDERA
Credential:
Phone: 952-941-7393