=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336568781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRGINIA FAMILY DENTAL P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2014
-----------------------------------------------------
Last Update Date | 04/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 802 4TH ST N
-----------------------------------------------------
City | VIRGINIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55792-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-741-0405
-----------------------------------------------------
Fax | 218-741-1445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 802 4TH ST N
-----------------------------------------------------
City | VIRGINIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55792-2451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-741-0405
-----------------------------------------------------
Fax | 218-741-1445
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. MICHAEL BRYAN MISKOVICH
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 218-741-0405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | D12649
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------