Healthcare Provider Details

I. General information

NPI: 1114832839
Provider Name (Legal Business Name): SHINE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 4TH ST SE STE 200
SAINT CLOUD MN
56304-1245
US

IV. Provider business mailing address

1020 4TH ST SE STE 200
SAINT CLOUD MN
56304-1245
US

V. Phone/Fax

Practice location:
  • Phone: 320-980-6031
  • Fax:
Mailing address:
  • Phone: 320-980-6031
  • Fax:

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: MRS. MAHADO ONWUKWE
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 320-980-6031