Healthcare Provider Details

I. General information

NPI: 1700135845
Provider Name (Legal Business Name): MR. MENG VANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 7TH ST E
SAINT PAUL MN
55119-3419
US

IV. Provider business mailing address

4325 GRAND AVE
DULUTH MN
55807-2730
US

V. Phone/Fax

Practice location:
  • Phone: 651-735-0595
  • Fax: 651-735-0521
Mailing address:
  • Phone: 218-628-7035
  • Fax: 218-624-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125J00000X
TaxonomyDental Therapist
License NumberDT13
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: