Healthcare Provider Details

I. General information

NPI: 1174547855
Provider Name (Legal Business Name): JOHN D. NYDAHL, DDS, P. A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 2ND ST N STE 101
SAINT CLOUD MN
56303-3237
US

IV. Provider business mailing address

1011 2ND ST N STE 101
SAINT CLOUD MN
56303-3237
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-0744
  • Fax: 320-253-9930
Mailing address:
  • Phone: 320-253-0744
  • Fax: 320-253-9930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD8204
License Number StateMN

VIII. Authorized Official

Name: JOHN D. NYDAHL
Title or Position: PRESIDENT
Credential: DDS
Phone: 320-253-0744