=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245639517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARTISAN DENTAL. P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2014
-----------------------------------------------------
Last Update Date | 08/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 ANNAPOLIS LN SUITE 103.
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-519-8880
-----------------------------------------------------
Fax | 763-519-8881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000-ANNAPOLIS LN. SUITE 103.
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-519-8880
-----------------------------------------------------
Fax | 763-519-8881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KAMAL AHMED
-----------------------------------------------------
Credential | BDS.
-----------------------------------------------------
Telephone | 763-519-8880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 58780
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D11984
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------