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General NPI Number Information
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NPI Number | 1093044869
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Entity Type | Organization
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Legal Business Name | HEALTHY TEETH CLUB
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Dates
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Enumeration Date | 12/08/2009
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Last Update Date | 12/08/2009
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Provider Practice Location Address
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Address Line | 13410 CANALVILLE LANE
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City | GRASSTON
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State | MN
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Zip | 55030-2162
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Country | US
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Telephone | 651-894-4391
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Fax |
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Provider Business Mailing Address
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Address Line | 13410 CANALVILLE LANE
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City | GRASSTON
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State | MN
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Zip | 55030-2162
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Country | US
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Telephone | 651-894-4391
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Fax |
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Authorized Official
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Title or Position | DENTAL HYGIENIST
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Name | MRS. REBECCA LYNNE FAHNING
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Credential | RDH,BS
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Telephone | 651-894-4391
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number |
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License Number State |
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