Healthcare Provider Details

I. General information

NPI: 1275362329
Provider Name (Legal Business Name): HER AND MAN TOWN DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 RICHARD AVE STE 103
HERMANTOWN MN
55811-2979
US

IV. Provider business mailing address

4135 RICHARD AVE STE 103
HERMANTOWN MN
55811-2979
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-2428
  • Fax: 218-722-0142
Mailing address:
  • Phone: 218-722-2428
  • Fax: 218-722-0142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TRACEY MAKITALO
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 218-722-2428