Healthcare Provider Details

I. General information

NPI: 1609272822
Provider Name (Legal Business Name): ROCHESTER PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2014
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 S BORADWAY AVE STE B
ROCHESTER MN
55904-7960
US

IV. Provider business mailing address

1705 S BORADWAY AVE STE B
ROCHESTER MN
55904-7960
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-0102
  • Fax: 507-252-1445
Mailing address:
  • Phone: 507-288-0102
  • Fax: 507-252-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD13120
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLY AMANDA JONES
Title or Position: PEDIATRIC DENTIST, OWNER
Credential: D.D.S.
Phone: 608-206-1233