Healthcare Provider Details

I. General information

NPI: 1144150384
Provider Name (Legal Business Name): JACK DAILEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 E LAKE ST
MINNEAPOLIS MN
55406-2259
US

IV. Provider business mailing address

6399 BARRIE RD
EDINA MN
55435-2201
US

V. Phone/Fax

Practice location:
  • Phone: 612-721-2424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD15432
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: