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General NPI Number Information
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NPI Number | 1003886383
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Entity Type | Organization
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Legal Business Name | COMMUNITY DENTAL CARE INC
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Dates
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Enumeration Date | 01/26/2006
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Last Update Date | 07/24/2025
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Provider Practice Location Address
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Address Line | 600 CARLTON STREET N
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City | MAPLEWOOD
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State | MN
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Zip | 55119
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Country | US
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Telephone | 651-774-2959
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Fax | 651-774-1997
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Provider Business Mailing Address
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Address Line | 1670 BEAM AVE
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City | MAPLEWOOD
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State | MN
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Zip | 55109
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Country | US
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Telephone | 651-925-8400
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Fax | 651-925-8439
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Authorized Official
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Title or Position | HR DIRECTOR
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Name | DR. KORI C CARLSON
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Credential |
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Telephone | 651-925-8427
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 460668000
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License Number State | MN
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