=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033307046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOORSTEP HEALTHCARE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2007
-----------------------------------------------------
Last Update Date | 06/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5861 CEDAR LAKE RD S
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-1481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-541-6000
-----------------------------------------------------
Fax | 763-277-5227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5861 CEDAR LAKE RD S
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-1481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-541-6000
-----------------------------------------------------
Fax | 763-277-5227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LYNNE MADER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-541-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 734432000
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------