=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124663109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER ROLAND DEGALLIER DENTAL THERAPIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2019
-----------------------------------------------------
Last Update Date | 11/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 E HIGHWAY 61
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55987-5300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-452-9453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 E HIGHWAY 61
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55987-5300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-452-9453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 125J00000X
-----------------------------------------------------
Taxonomy Name | Dental Therapist
-----------------------------------------------------
License Number | DT117
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------