=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285136242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERRY DENTAL, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2018
-----------------------------------------------------
Last Update Date | 03/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 N. LAKESHORE DR.
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-345-4677
-----------------------------------------------------
Fax | 651-345-0177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 N. LAKESHORE DR
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-345-4677
-----------------------------------------------------
Fax | 651-345-0177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS
-----------------------------------------------------
Name | MISS AVA M. PERRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-345-4677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D13823
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------