Healthcare Provider Details

I. General information

NPI: 1114130010
Provider Name (Legal Business Name): NORTHWEST FAMILY DENTAL CENTER TN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12725 43RD ST NE SUITE 202
SAINT MICHAEL MN
55376-4900
US

IV. Provider business mailing address

12725 43RD ST NE SUITE 202
SAINT MICHAEL MN
55376-4900
US

V. Phone/Fax

Practice location:
  • Phone: 763-497-2367
  • Fax: 763-497-8171
Mailing address:
  • Phone: 763-497-2367
  • Fax: 763-497-8171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8424
License Number StateMN

VIII. Authorized Official

Name: DAVID A. DESIMONE
Title or Position: OWNER
Credential: D.D.S.
Phone: 763-497-2367