Healthcare Provider Details

I. General information

NPI: 1265213441
Provider Name (Legal Business Name): SHANA MARIE BUERCK LDH, DT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANA MARIE ATKINSON LDH

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 10/12/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 COUNTY HWY 10
MOUNDS VIEW MN
55112
US

IV. Provider business mailing address

108 BICHNER LN
MAHTOMEDI MN
55115-6810
US

V. Phone/Fax

Practice location:
  • Phone: 763-316-5400
  • Fax:
Mailing address:
  • Phone: 651-983-1429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT159
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: