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General NPI Number Information
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NPI Number | 1104400845
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Entity Type | Organization
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Legal Business Name | HAM LAKE DENTAL PLLC
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Dates
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Enumeration Date | 05/10/2021
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Last Update Date | 05/10/2021
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Provider Practice Location Address
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Address Line | 16220 ABERDEEN ST NE STE A1
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City | ANDOVER
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State | MN
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Zip | 55304-5421
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Country | US
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Telephone | 763-415-7831
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Fax |
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Provider Business Mailing Address
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Address Line | 16220 ABERDEEN ST NE STE A1
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City | ANDOVER
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State | MN
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Zip | 55304-5421
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Country | US
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Telephone | 763-415-7831
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ALEX SHNAYDRUK
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Credential | DDS
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Telephone | 952-261-4307
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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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