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General NPI Number Information
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NPI Number | 1194886630
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Entity Type | Organization
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Legal Business Name | SCANDIA FAMILY DENTAL PA
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 21080 OLINDA TRAIL N
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City | SCANDIA
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State | MN
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Zip | 55073
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Country | US
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Telephone | 651-433-2655
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Fax | 651-433-2655
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Provider Business Mailing Address
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Address Line | 21080 OLINDA TRAIL N
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City | SCANDIA
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State | MN
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Zip | 55073
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Country | US
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Telephone | 651-433-2655
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Fax | 651-433-2655
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Authorized Official
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Title or Position | DENTIST
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Name | MICHELE MARIE REVOIR
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Credential | DDS
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Telephone | 651-433-2655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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