Healthcare Provider Details

I. General information

NPI: 1497890594
Provider Name (Legal Business Name): MICHAEL K SUTLEY DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD9086
License Number StateMN

VIII. Authorized Official

Name: DR. MICHAEL K SUTLEY
Title or Position: PRESIDENT
Credential: DDS
Phone: 612-333-3381