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General NPI Number Information
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NPI Number | 1124478607
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Entity Type | Organization
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Legal Business Name | MINNESOTA DENTAL SURGERY PLLC
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Dates
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Enumeration Date | 06/15/2016
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Last Update Date | 06/15/2016
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Provider Practice Location Address
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Address Line | 9801 DUPONT AVE S
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City | BLOOMINGTON
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State | MN
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Zip | 55431-3100
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Country | US
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Telephone | 952-215-7419
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Fax |
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Provider Business Mailing Address
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Address Line | 3510 120TH ST W
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City | ROSEMOUNT
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State | MN
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Zip | 55068-3501
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Country | US
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Telephone | 952-215-7419
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. BENNETT ISABELLA
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Credential | DDS
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Telephone | 952-215-7419
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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 | D12540
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License Number State | MN
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