Healthcare Provider Details

I. General information

NPI: 1457313587
Provider Name (Legal Business Name): EDWARD MARTEL DENNISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4194 LEXINGTON AVE N
SHOREVIEW MN
55126-6106
US

IV. Provider business mailing address

PO BOX 43 MR 10809
MINNEAPOLIS MN
55440-0043
US

V. Phone/Fax

Practice location:
  • Phone: 651-483-5461
  • Fax:
Mailing address:
  • Phone: 612-262-4813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28499
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: