Healthcare Provider Details

I. General information

NPI: 1497365134
Provider Name (Legal Business Name): LAYTON MIKKALSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15535 34TH AVE N STE 200
PLYMOUTH MN
55447-2170
US

IV. Provider business mailing address

15535 34TH AVE N STE 200
PLYMOUTH MN
55447-2170
US

V. Phone/Fax

Practice location:
  • Phone: 763-233-3359
  • Fax:
Mailing address:
  • Phone: 763-233-3359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD14449
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: