Healthcare Provider Details

I. General information

NPI: 1487691887
Provider Name (Legal Business Name): DENNIS LEE NIERENGARTEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 NORTHWAY DR SUITE 102
SAINT CLOUD MN
56303-1261
US

IV. Provider business mailing address

1511 NORTHWAY DR SUITE 102
SAINT CLOUD MN
56303-1261
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-1020
  • Fax: 320-255-1732
Mailing address:
  • Phone: 320-255-1020
  • Fax: 320-255-1732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9004
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: