=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255828059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUESTEM DENTAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2018
-----------------------------------------------------
Last Update Date | 04/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 13TH ST S
-----------------------------------------------------
City | BENSON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56215-1821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-842-4191
-----------------------------------------------------
Fax | 320-843-4208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 13TH ST S
-----------------------------------------------------
City | BENSON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56215-1821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-842-4191
-----------------------------------------------------
Fax | 320-843-4208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY - TREASURER
-----------------------------------------------------
Name | MS. NANCY MARIE HILLEREN
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 320-444-4033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------