Healthcare Provider Details

I. General information

NPI: 1538765029
Provider Name (Legal Business Name): MINNESOTA LAKES DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 MAINE AVE SE STE 200
ROCHESTER MN
55904-6936
US

IV. Provider business mailing address

4270 MAINE AVE SE STE 200
ROCHESTER MN
55904-6936
US

V. Phone/Fax

Practice location:
  • Phone: 507-282-4401
  • Fax: 507-282-4407
Mailing address:
  • Phone: 507-282-4401
  • Fax: 507-282-4407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARSHALL MORRIS
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 507-282-4401