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General NPI Number Information
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NPI Number | 1053834481
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Entity Type | Organization
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Legal Business Name | MONDALE DENTAL LLC
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Dates
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Enumeration Date | 07/18/2017
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Last Update Date | 07/30/2024
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Provider Practice Location Address
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Address Line | 10600 OLD COUNTY RD 15 SUITE 120
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City | PLYMOUTH
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State | MN
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Zip | 55441-6205
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Country | US
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Telephone | 763-512-8500
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Fax | 763-512-8592
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Provider Business Mailing Address
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Address Line | 10600 OLD COUNTY RD 15 SUITE 120
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City | PLYMOUTH
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State | MN
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Zip | 55441-6205
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Country | US
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Telephone | 763-512-8500
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Fax | 763-512-8592
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Authorized Official
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Title or Position | OWNER SOLE MEMBER
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Name | MR. BRIAN PATRICK MONDALE
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Credential | D.D.S.
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Telephone | 763-512-8500
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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