Healthcare Provider Details

I. General information

NPI: 1154556561
Provider Name (Legal Business Name): REBECCA LOUISE DEWOLF FELICES DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 COUNTY HIGHWAY 10
MOUNDS VIEW MN
55112
US

IV. Provider business mailing address

2442 COUNTY HIGHWAY 10
MOUNDS VIEW MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 763-316-5400
  • Fax: 763-780-9005
Mailing address:
  • Phone: 763-316-5400
  • Fax: 763-316-5406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1855129
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12909
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: