Healthcare Provider Details

I. General information

NPI: 1124304373
Provider Name (Legal Business Name): ANDRADA LAVINIA HRDLICKA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 7TH ST W
SAINT PAUL MN
55102-3828
US

IV. Provider business mailing address

1026 7TH ST W
SAINT PAUL MN
55102-3828
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-1000
  • Fax: 651-241-1138
Mailing address:
  • Phone: 651-241-1000
  • Fax: 651-241-1138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH8357
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number906414
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: