Healthcare Provider Details

I. General information

NPI: 1083789929
Provider Name (Legal Business Name): EDINA 5-O DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3948 W 50TH ST SUITE 205
EDINA MN
55424
US

IV. Provider business mailing address

3948 W 50TH ST SUITE 205
EDINA MN
55424
US

V. Phone/Fax

Practice location:
  • Phone: 952-922-8111
  • Fax: 952-922-2125
Mailing address:
  • Phone: 952-922-8111
  • Fax: 952-922-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10569
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10569
License Number StateMN

VIII. Authorized Official

Name: DR. DREW F SPENCER
Title or Position: DENTIST OWNER
Credential: DDS
Phone: 952-922-8111