Healthcare Provider Details

I. General information

NPI: 1730360355
Provider Name (Legal Business Name): KOALA DENTAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 12/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 VETERANS DRIVE SUITE 102
SAINT CLOUD MN
56303
US

IV. Provider business mailing address

3950 VETERANS DRIVE SUITE 102
SAINT CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-8380
  • Fax: 320-253-8419
Mailing address:
  • Phone: 320-253-8380
  • Fax: 320-253-8419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN DAIVD COLLIER
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 320-253-8380