Healthcare Provider Details

I. General information

NPI: 1912143843
Provider Name (Legal Business Name): DENTAL SPECIALISTS OF MINNESOTA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2008
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9325 UPLAND LN N SUITE 330
MAPLE GROVE MN
55369-4200
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 763-416-0037
  • Fax:
Mailing address:
  • Phone: 651-633-0500
  • Fax: 651-636-6350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: ALAN LAW
Title or Position: PRESIDENT
Credential: DDS, PHD
Phone: 651-633-0500