Healthcare Provider Details

I. General information

NPI: 1750519930
Provider Name (Legal Business Name): MALINA TEODORU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13550 26TH AVE N
PLYMOUTH MN
55441-3650
US

IV. Provider business mailing address

14376 ASPEN AVE NE
PRIOR LAKE MN
55372-1307
US

V. Phone/Fax

Practice location:
  • Phone: 763-557-0287
  • Fax: 763-557-0295
Mailing address:
  • Phone: 952-992-0282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12674
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12674
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: