Healthcare Provider Details

I. General information

NPI: 1215980008
Provider Name (Legal Business Name): DEAN K KNUDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 FORD ROAD UNIT B
ST LOUIS PARK MN
55426
US

IV. Provider business mailing address

1155 FORD ROAD UNIT B
ST LOUIS PARK MN
55426
US

V. Phone/Fax

Practice location:
  • Phone: 952-378-1800
  • Fax: 952-378-1714
Mailing address:
  • Phone: 952-378-1800
  • Fax: 952-378-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31928
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number031928
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: