Healthcare Provider Details

I. General information

NPI: 1659204584
Provider Name (Legal Business Name): SCOTT JAMES IMBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16220 ABERDEEN ST NE STE A1
HAM LAKE MN
55304-5421
US

IV. Provider business mailing address

90 S 9TH ST APT 1308
MINNEAPOLIS MN
55402-3279
US

V. Phone/Fax

Practice location:
  • Phone: 763-434-4188
  • Fax: 763-413-7261
Mailing address:
  • Phone: 218-269-3558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD15447
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: