Healthcare Provider Details

I. General information

NPI: 1871983478
Provider Name (Legal Business Name): DAKOTA MEDICAL CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 02/03/2015
Certification Date:
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

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

V. Phone/Fax

Practice location:
  • Phone: 952-924-1053
  • Fax: 952-924-0254
Mailing address:
  • Phone: 952-924-1053
  • Fax: 952-924-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number29325
License Number StateMN

VIII. Authorized Official

Name: MICHAEL DOLE
Title or Position: OWNER
Credential: M.D.
Phone: 952-924-1053