Healthcare Provider Details

I. General information

NPI: 1427027184
Provider Name (Legal Business Name): SOUTH LAKE CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17705 HUTCHINS DR SUITE 101
MINNETONKA MN
55345-4145
US

IV. Provider business mailing address

17705 HUTCHINS DR SUITE 101
MINNETONKA MN
55345-4145
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-8300
  • Fax: 952-401-8243
Mailing address:
  • Phone: 952-401-8300
  • Fax: 952-401-8243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number556
License Number StateMN

VIII. Authorized Official

Name: DR. DALE T DOBRIN
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 952-401-8300