Healthcare Provider Details

I. General information

NPI: 1548844053
Provider Name (Legal Business Name): PHONSUDA CHANTHAVISOUK RDH, MDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 E HENNEPIN AVE
MINNEAPOLIS MN
55414-1126
US

IV. Provider business mailing address

6145 14TH AVE S
MINNEAPOLIS MN
55423-1728
US

V. Phone/Fax

Practice location:
  • Phone: 612-746-1530
  • Fax:
Mailing address:
  • Phone: 612-961-9886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT137
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH11002
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: