Healthcare Provider Details

I. General information

NPI: 1003886383
Provider Name (Legal Business Name): COMMUNITY DENTAL CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/24/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CARLTON STREET N
MAPLEWOOD MN
55119
US

IV. Provider business mailing address

1670 BEAM AVE
MAPLEWOOD MN
55109
US

V. Phone/Fax

Practice location:
  • Phone: 651-774-2959
  • Fax: 651-774-1997
Mailing address:
  • Phone: 651-925-8400
  • Fax: 651-925-8439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number460668000
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KORI C CARLSON
Title or Position: HR DIRECTOR
Credential:
Phone: 651-925-8427