=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225786411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PL DENTAL SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2022
-----------------------------------------------------
Last Update Date | 05/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12628 FREMONT AVE
-----------------------------------------------------
City | ZIMMERMAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55398-9735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-217-5959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9920 FOLEY BLVD NW STE 110
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-5216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 633-171-1667
-----------------------------------------------------
Fax | 763-317-1167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PHONG VINH LY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 763-317-1168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------