Healthcare Provider Details

I. General information

NPI: 1386189801
Provider Name (Legal Business Name): ON-SITE DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 FRANCE AVE. S. SUITE 1100
EDINA MN
55130-5924
US

IV. Provider business mailing address

7600 FRANCE AVE. S. SUITE 1100
EDINA MN
55436-5924
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 Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN CHARLES FINCHAM
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 612-961-0866