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General NPI Number Information
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NPI Number | 1265213441
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Entity Type | Individual
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Provider Name | SHANA MARIE BUERCK LDH, DT
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Gender | Female
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Dates
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Enumeration Date | 10/12/2023
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Last Update Date | 10/12/2023
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Provider Practice Location Address
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Address Line | 2442 COUNTY HWY 10
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City | MOUNDS VIEW
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State | MN
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Zip | 55112
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Country | US
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Telephone | 763-316-5400
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Fax |
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Provider Business Mailing Address
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Address Line | 108 BICHNER LN
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City | MAHTOMEDI
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State | MN
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Zip | 55115-6810
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Country | US
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Telephone | 651-983-1429
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 125J00000X
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Taxonomy Name | Dental Therapist
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License Number | DT159
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License Number State | MN
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