Healthcare Provider Details

I. General information

NPI: 1750109351
Provider Name (Legal Business Name): REVIVE DENTAL SOLUTIONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 WINNETKA AVE N
NEW HOPE MN
55427-2830
US

IV. Provider business mailing address

5727 W 42ND ST
ST LOUIS PARK MN
55416-3101
US

V. Phone/Fax

Practice location:
  • Phone: 763-545-3010
  • Fax: 763-595-0543
Mailing address:
  • Phone: 612-275-1846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ELIZABETH K LAABS
Title or Position: DENTIST
Credential: DDS
Phone: 763-545-3010