Healthcare Provider Details

I. General information

NPI: 1376872473
Provider Name (Legal Business Name): SHYLO ECKSTROM R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 BROADWAY ST NE
MINNEAPOLIS MN
55413-2164
US

IV. Provider business mailing address

636 BROADWAY ST NE
MINNEAPOLIS MN
55413-2164
US

V. Phone/Fax

Practice location:
  • Phone: 612-746-1530
  • Fax: 612-746-1531
Mailing address:
  • Phone: 612-746-1530
  • Fax: 612-746-1531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH8199
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: