Healthcare Provider Details

I. General information

NPI: 1326044538
Provider Name (Legal Business Name): SOUTHDALE PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 FRANCE AVE S STE 190
EDINA MN
55435-2184
US

IV. Provider business mailing address

6545 FRANCE AVE S STE 190
EDINA MN
55435-2184
US

V. Phone/Fax

Practice location:
  • Phone: 952-922-6949
  • Fax: 952-922-9287
Mailing address:
  • Phone: 952-922-6949
  • Fax: 952-922-9287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number8863
License Number StateMN

VIII. Authorized Official

Name: DR. JAMES R JENSEN
Title or Position: OWNER
Credential: DDS MS
Phone: 952-922-6949