=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114360492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSIDE EDGE DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2013
-----------------------------------------------------
Last Update Date | 02/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1346 PAYNE AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55130-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-774-6085
-----------------------------------------------------
Fax | 651-774-2660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1346 PAYNE AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55130-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-774-6085
-----------------------------------------------------
Fax | 651-774-2660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS/PRESIDENT
-----------------------------------------------------
Name | JENNIFER A MARKER JOHNSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 651-774-6085
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------