Healthcare Provider Details

I. General information

NPI: 1346316189
Provider Name (Legal Business Name): DENTAL SPECIALISTS OF MINNESOTA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8650 HUDSON BLVD N SUITE 105
LAKE ELMO MN
55042-9747
US

IV. Provider business mailing address

2200 COUNTY ROAD C W SUITE 2210
ROSEVILLE MN
55113-2550
US

V. Phone/Fax

Practice location:
  • Phone: 651-714-9477
  • Fax:
Mailing address:
  • Phone: 651-633-0500
  • Fax: 651-636-6350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ALAN LAW
Title or Position: PRESIDENT
Credential: D.D.S., PHD
Phone: 651-633-0500