=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306236708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPLANT AND PERIODONTAL PROFESSIONALS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2015
-----------------------------------------------------
Last Update Date | 01/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3142 WELLNER DR NE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55906-8388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-206-6452
-----------------------------------------------------
Fax | 507-206-6186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3142 WELLNER DR NE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55906-8388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-206-6452
-----------------------------------------------------
Fax | 507-206-6186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERIODONTITIST
-----------------------------------------------------
Name | DR. EMILY SCHMALZ KELLY
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 651-261-3644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | D12773
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------