Healthcare Provider Details

I. General information

NPI: 1003431263
Provider Name (Legal Business Name): DENTAL SPECIALISTS OF MINNESOTA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2020
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14525 HIGHWAY 7 STE 125
MINNETONKA MN
55345-3738
US

IV. Provider business mailing address

2200 COUNTY ROAD C W STE 2210
ROSEVILLE MN
55113-2551
US

V. Phone/Fax

Practice location:
  • Phone: 952-303-8858
  • Fax: 952-314-4892
Mailing address:
  • Phone: 651-746-2815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: SHANNON HESSE
Title or Position: CREDENTIALING SPECIALISTS
Credential:
Phone: 651-746-2815