=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326023474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFINITY DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 5TH ST E STE 299
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55101-1898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-224-7470
-----------------------------------------------------
Fax | 651-298-0122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 5TH ST E STE 299
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55101-1898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-224-7470
-----------------------------------------------------
Fax | 651-298-0122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TODD ALAN PORTER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 651-224-7470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D11535
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------