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General NPI Number Information
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NPI Number | 1174547855
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Entity Type | Organization
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Legal Business Name | JOHN D. NYDAHL, DDS, P. A.
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Dates
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Enumeration Date | 07/27/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1011 2ND ST N STE 101
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City | SAINT CLOUD
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State | MN
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Zip | 56303-3237
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Country | US
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Telephone | 320-253-0744
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Fax | 320-253-9930
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Provider Business Mailing Address
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Address Line | 1011 2ND ST N STE 101
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City | SAINT CLOUD
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State | MN
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Zip | 56303-3237
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Country | US
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Telephone | 320-253-0744
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Fax | 320-253-9930
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN D. NYDAHL
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Credential | DDS
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Telephone | 320-253-0744
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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 | D8204
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License Number State | MN
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