Healthcare Provider Details

I. General information

NPI: 1962676825
Provider Name (Legal Business Name): OTSEGO DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9075 QUADAY AVE NE SUITE 101
OTSEGO MN
55330-6672
US

IV. Provider business mailing address

9075 QUADAY AVE NE SUITE 101
OTSEGO MN
55330-6672
US

V. Phone/Fax

Practice location:
  • Phone: 763-441-2452
  • Fax: 763-441-7675
Mailing address:
  • Phone: 763-441-2452
  • Fax: 763-441-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10405
License Number StateMN

VIII. Authorized Official

Name: PAUL SHEILS
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 763-441-2452