Healthcare Provider Details

I. General information

NPI: 1588765754
Provider Name (Legal Business Name): CORY REID HERMAN DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DELAWARE ST SE SCHOOL OF DENTISTRY
MINNEAPOLIS MN
55455-0357
US

IV. Provider business mailing address

515 DELAWARE ST SE TMJ CLINIC
MINNEAPOLIS MN
55455-0357
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-6529
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11242
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License NumberD11242
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: