Healthcare Provider Details

I. General information

NPI: 1669471900
Provider Name (Legal Business Name): MICHAEL A DOLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3408 DAKOTA AVE S
ST LOUIS PARK MN
55416-2312
US

IV. Provider business mailing address

PO BOX 43 MR 10809
MINNEAPOLIS MN
55440-0043
US

V. Phone/Fax

Practice location:
  • Phone: 952-924-1053
  • Fax: 952-924-0254
Mailing address:
  • Phone: 612-262-4813
  • Fax: 612-262-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29325
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: