Healthcare Provider Details

I. General information

NPI: 1801159207
Provider Name (Legal Business Name): ANGELA VETTRUS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WOODLAKE DR SE STE B
ROCHESTER MN
55904-4514
US

IV. Provider business mailing address

1504 25TH AVE NW
FARIBAULT MN
55021-3415
US

V. Phone/Fax

Practice location:
  • Phone: 763-784-7993
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5993
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: