Healthcare Provider Details

I. General information

NPI: 1487147260
Provider Name (Legal Business Name): HANOVER DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 LABEAUX AVE NE
HANOVER MN
55341
US

IV. Provider business mailing address

1192 BICE AVE NW
BUFFALO MN
55313-4456
US

V. Phone/Fax

Practice location:
  • Phone: 763-400-3005
  • Fax:
Mailing address:
  • Phone: 763-226-7379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD13236
License Number StateMN

VIII. Authorized Official

Name: DR. TYLER JAMES KOIVISTO
Title or Position: DENTIST
Credential: DDS
Phone: 763-226-7379