Healthcare Provider Details

I. General information

NPI: 1558120519
Provider Name (Legal Business Name): ARCHITA JAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DELAWARE ST SE
MINNEAPOLIS MN
55455-0357
US

IV. Provider business mailing address

515 DELAWARE ST SE
MINNEAPOLIS MN
55455-0357
US

V. Phone/Fax

Practice location:
  • Phone: 612-594-6778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDR61546849
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD15342
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: