Healthcare Provider Details

I. General information

NPI: 1740510510
Provider Name (Legal Business Name): HEALTHY TEETH CLUB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13410 CANALVILLE LN
GRASSTON MN
55030-2162
US

IV. Provider business mailing address

13410 CANALVILLE LN
GRASSTON MN
55030-2162
US

V. Phone/Fax

Practice location:
  • Phone: 651-894-4391
  • Fax:
Mailing address:
  • Phone: 651-894-4391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5749
License Number StateMN

VIII. Authorized Official

Name: MRS. REBECCA L FAHNING
Title or Position: COLLABORATIVE DENTAL HYGIENIST
Credential: RDH,BS
Phone: 651-894-4391