Healthcare Provider Details

I. General information

NPI: 1326398025
Provider Name (Legal Business Name): ROCHESTER ENDODONTICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 ELTON HILLS LN NW SUITE 100
ROCHESTER MN
55901-3602
US

IV. Provider business mailing address

116 ELTON HILLS LN NW SUITE 100
ROCHESTER MN
55901-3602
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-8363
  • Fax: 507-288-4456
Mailing address:
  • Phone: 507-288-8363
  • Fax: 507-288-4456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD8111
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD13634
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD11595
License Number StateMN

VIII. Authorized Official

Name: DR. GERALD J GRAY
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 507-272-4912