Healthcare Provider Details

I. General information

NPI: 1639398886
Provider Name (Legal Business Name): TOWN DENTAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 2ND ST
EXCELSIOR MN
55331-2038
US

IV. Provider business mailing address

700 WESTON RIDGE PKWY
CHASKA MN
55318-1202
US

V. Phone/Fax

Practice location:
  • Phone: 952-474-6133
  • Fax:
Mailing address:
  • Phone: 952-368-3356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11057
License Number StateMN

VIII. Authorized Official

Name: DR. DAVID J HARVIEUX
Title or Position: VICE PRESIDENT
Credential: DENTIST
Phone: 952-474-6133