Healthcare Provider Details

I. General information

NPI: 1093704520
Provider Name (Legal Business Name): JILL HEATHER PUCEL-KOOPMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14115 JAMES RD SUITE 303
ROGERS MN
55374-9468
US

IV. Provider business mailing address

14115 JAMES RD SUITE 303
ROGERS MN
55374-9468
US

V. Phone/Fax

Practice location:
  • Phone: 763-428-2226
  • Fax: 763-428-3407
Mailing address:
  • Phone: 763-428-2226
  • Fax: 763-428-3407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11666
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: