Healthcare Provider Details

I. General information

NPI: 1154989507
Provider Name (Legal Business Name): RED OAK FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 05/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9939 HUDSON BLVD N # 107
LAKE ELMO MN
55042-4109
US

IV. Provider business mailing address

9090 RED OAK TRL
WOODBURY MN
55129-2210
US

V. Phone/Fax

Practice location:
  • Phone: 651-300-2334
  • Fax:
Mailing address:
  • Phone: 651-226-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATRINA ANDRADA LEANO
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 651-226-1029