Healthcare Provider Details

I. General information

NPI: 1841915741
Provider Name (Legal Business Name): NICOLLET FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2738 WINNETKA AVE N STE 100
NEW HOPE MN
55427-2877
US

IV. Provider business mailing address

2738 WINNETKA AVE N STE 100
NEW HOPE MN
55427-2877
US

V. Phone/Fax

Practice location:
  • Phone: 612-870-4646
  • Fax:
Mailing address:
  • Phone: 612-870-4646
  • Fax: 763-717-8491

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. TRACEY ROSEANN CHARLES
Title or Position: DOCTOR/OWNER
Credential: DDS
Phone: 612-870-4646