Healthcare Provider Details

I. General information

NPI: 1316000755
Provider Name (Legal Business Name): MICHAEL K SUTLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NICOLLET MALL SUITE 707 MEDICAL ARTS BLDG
MINNEAPOLIS MN
55402-2606
US

IV. Provider business mailing address

6406 TIMBER RDG
EDINA MN
55439-1057
US

V. Phone/Fax

Practice location:
  • Phone: 612-333-3381
  • Fax: 612-334-3318
Mailing address:
  • Phone: 952-944-5735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9086
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: