=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346896297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRONTLINE DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2019
-----------------------------------------------------
Last Update Date | 08/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4045 BROOKSIDE AVE
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-225-7033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6973 ARCHER PL
-----------------------------------------------------
City | INVER GROVE HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55077-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-225-7033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ERNEST JUEAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 763-225-7033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------