Healthcare Provider Details

I. General information

NPI: 1528558244
Provider Name (Legal Business Name): ON-SITE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 FRANCE AVE S STE 1100
EDINA MN
55435-5936
US

IV. Provider business mailing address

7600 FRANCE AVE S STE 1100
EDINA MN
55435-5936
US

V. Phone/Fax

Practice location:
  • Phone: 763-545-7545
  • Fax: 952-929-2067
Mailing address:
  • Phone: 763-545-7545
  • Fax: 952-929-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN FINCHAM
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 763-545-7545