Healthcare Provider Details

I. General information

NPI: 1194886630
Provider Name (Legal Business Name): SCANDIA FAMILY DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21080 OLINDA TRAIL N
SCANDIA MN
55073
US

IV. Provider business mailing address

21080 OLINDA TRAIL N
SCANDIA MN
55073
US

V. Phone/Fax

Practice location:
  • Phone: 651-433-2655
  • Fax: 651-433-2655
Mailing address:
  • Phone: 651-433-2655
  • Fax: 651-433-2655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MICHELE MARIE REVOIR
Title or Position: DENTIST
Credential: DDS
Phone: 651-433-2655