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General NPI Number Information
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NPI Number | 1144267063
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Entity Type | Organization
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Legal Business Name | CENTRAL MN PEDIATRIC DENTISTS PA
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Dates
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Enumeration Date | 05/31/2006
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Last Update Date | 06/18/2013
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Provider Practice Location Address
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Address Line | 1900 CENTRACARE CIRCLE STE 0350
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City | ST CLOUD
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State | MN
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Zip | 56303-5000
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Country | US
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Telephone | 320-253-0272
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Fax | 320-251-2661
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Provider Business Mailing Address
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Address Line | 1900 CENTRACARE CIRCLE STE 0350
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City | ST CLOUD
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State | MN
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Zip | 56303-5000
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Country | US
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Telephone | 320-253-0272
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Fax | 320-251-2661
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOSEPH HALL WENNER
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Credential | DDS
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Telephone | 320-253-0272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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