Healthcare Provider Details

I. General information

NPI: 1457602211
Provider Name (Legal Business Name): CARRIE AGNES ALTRICHTER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARRIE AGNES WOLF RDH

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 03/17/2018
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

145 KANGAS RD
ESKO MN
55733-9738
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: