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General NPI Number Information
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NPI Number | 1063768687
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Entity Type | Organization
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Legal Business Name | BLAINE DENTAL LLC DBA PRO DENTAL
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Dates
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Enumeration Date | 08/01/2012
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Last Update Date | 08/01/2012
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Provider Practice Location Address
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Address Line | 10210 BALTIMORE ST NE SUITE 100
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City | BLAINE
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State | MN
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Zip | 55449-6049
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Country | US
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Telephone | 763-231-2050
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Fax | 763-231-2052
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Provider Business Mailing Address
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Address Line | 10210 BALTIMORE ST NE SUITE 100
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City | BLAINE
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State | MN
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Zip | 55449-6049
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Country | US
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Telephone | 763-231-2050
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Fax | 763-231-2052
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Authorized Official
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Title or Position | BDS
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Name | DR. ARIF NAZIR
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Credential | BDS
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Telephone | 763-231-2050
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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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