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General NPI Number Information
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NPI Number | 1043265481
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Entity Type | Organization
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Legal Business Name | NORTHSTAR DENTAL CLINIC PA
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Dates
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Enumeration Date | 05/24/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 675 E NICOLLET BLVD SUITE 120
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City | BURNSVILLE
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State | MN
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Zip | 55337-6741
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Country | US
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Telephone | 952-892-7700
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Fax | 952-892-7767
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Provider Business Mailing Address
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Address Line | 675 E NICOLLET BLVD SUITE 120
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City | BURNSVILLE
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State | MN
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Zip | 55337-6741
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Country | US
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Telephone | 952-892-7700
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Fax | 952-892-7767
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | MICHAEL SHAWN NANNE
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Credential | DDS
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Telephone | 952-892-7700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 10615
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License Number State | MN
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