Healthcare Provider Details

I. General information

NPI: 1124618962
Provider Name (Legal Business Name): JT DENTAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15180 CHIPPENDALE AVE W
ROSEMOUNT MN
55068-1523
US

IV. Provider business mailing address

15180 CHIPPENDALE AVE W
ROSEMOUNT MN
55068-1523
US

V. Phone/Fax

Practice location:
  • Phone: 651-423-1900
  • Fax: 651-423-6595
Mailing address:
  • Phone: 651-423-1900
  • Fax: 651-423-6595

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: DR. JASON JON THIMJON
Title or Position: OWNER/DOCTOR
Credential: DDS
Phone: 651-423-1900