Healthcare Provider Details

I. General information

NPI: 1932836509
Provider Name (Legal Business Name): SAVANNA JOY MIKKALSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DELAWARE ST SE
MINNEAPOLIS MN
55455-0357
US

IV. Provider business mailing address

14400 38TH AVE N
PLYMOUTH MN
55446-3329
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-5110
  • Fax:
Mailing address:
  • Phone: 763-442-7457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberR923
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: