Healthcare Provider Details

I. General information

NPI: 1649550260
Provider Name (Legal Business Name): CHRISTY JO FOGARTY RDH, ADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 11/14/2017
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 TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5961
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT02
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: