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General NPI Number Information
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NPI Number | 1295867562
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Entity Type | Individual
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Provider Name | LINDA M MAYTAN DDS
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Gender | Female
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 08/27/2015
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Provider Practice Location Address
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Address Line | 400 4TH ST NW SUITE A3A
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City | FARIBAULT
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State | MN
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Zip | 55021-5031
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Country | US
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Telephone | 507-384-6830
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Fax | 651-431-5575
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Provider Business Mailing Address
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Address Line | 400 4TH ST NW SOUTHERN CITIES CLINIC
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City | FARIBAULT
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State | MN
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Zip | 55021-5031
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Country | US
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Telephone | 507-384-6830
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Fax | 651-431-5575
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 11380
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 21230
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 21230
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License Number State | MA
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