Healthcare Provider Details

I. General information

NPI: 1164096665
Provider Name (Legal Business Name): OWATONNA ENDODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 28TH ST NE STE 1
OWATONNA MN
55060-2560
US

IV. Provider business mailing address

18599 VERNA LN
PRIOR LAKE MN
55372-9730
US

V. Phone/Fax

Practice location:
  • Phone: 507-242-1441
  • Fax:
Mailing address:
  • Phone: 215-667-9440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT THOMAS BEASLEY
Title or Position: DENTIST
Credential: DMD
Phone: 507-242-1441