Healthcare Provider Details

I. General information

NPI: 1083630586
Provider Name (Legal Business Name): CHILDREN'S DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7629 EGAN DR
SAVAGE MN
55378-2208
US

IV. Provider business mailing address

7629 EGAN DR
SAVAGE MN
55378-2208
US

V. Phone/Fax

Practice location:
  • Phone: 952-440-5100
  • Fax: 952-440-5140
Mailing address:
  • Phone: 952-440-5100
  • Fax: 952-400-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5460717
License Number StateMN

VIII. Authorized Official

Name: DR. GEORGE A HANKERSON
Title or Position: DENTIST
Credential: DDS
Phone: 952-997-7100