Healthcare Provider Details

I. General information

NPI: 1083712152
Provider Name (Legal Business Name): CRAIG W AMUNDSON DDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N SYNDICATE ST #300
SAINT PAUL MN
55104
US

IV. Provider business mailing address

MAIL CODE 21113A PO BOX 1309
MINNEAPOLIS MN
55440-1309
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-7373
  • Fax: 651-254-7383
Mailing address:
  • Phone: 952-883-5151
  • Fax: 952-883-5160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8378
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: