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General NPI Number Information
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NPI Number | 1043715204
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Entity Type | Organization
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Legal Business Name | MINNESOTA DENTAL PROFESSIONALS, P.C.
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Dates
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Enumeration Date | 03/28/2018
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Last Update Date | 06/05/2018
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Provider Practice Location Address
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Address Line | 16138 PILOT KNOB RD
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City | LAKEVILLE
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State | MN
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Zip | 55044
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Country | US
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Telephone | 952-679-7779
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Fax | 952-679-7778
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Provider Business Mailing Address
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Address Line | 16138 PILOT KNOB RD
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City | LAKEVILLE
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State | MN
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Zip | 55044-4105
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Country | US
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Telephone | 952-679-7779
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Fax | 952-679-7778
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | JESSICA BRITT
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Credential |
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Telephone | 217-540-8426
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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