Healthcare Provider Details

I. General information

NPI: 1588094171
Provider Name (Legal Business Name): ROSSODONTICS DENTAL SLEEP MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2013
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

368 LAKE ST S STE 101
FOREST LAKE MN
55025-2824
US

IV. Provider business mailing address

368 LAKE ST S STE 101
FOREST LAKE MN
55025-2824
US

V. Phone/Fax

Practice location:
  • Phone: 651-464-6988
  • Fax:
Mailing address:
  • Phone: 651-464-6988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY KENT ROSS
Title or Position: OWNER
Credential: D.D.S.
Phone: 651-207-9400