Healthcare Provider Details

I. General information

NPI: 1871509539
Provider Name (Legal Business Name): LYNNE MARIE CHILBERG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4163 HAINES RD
HERMANTOWN MN
55811-3942
US

IV. Provider business mailing address

4163 HAINES RD
HERMANTOWN MN
55811-3942
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-2428
  • Fax: 218-722-2428
Mailing address:
  • Phone: 218-722-2428
  • Fax: 218-722-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8735
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: