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General NPI Number Information
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NPI Number | 1386035590
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Entity Type | Organization
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Legal Business Name | MOORE LAKE DENTAL
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Dates
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Enumeration Date | 02/10/2015
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Last Update Date | 02/10/2015
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Provider Practice Location Address
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Address Line | 6230 HIGHWAY 65 NE SUITE 105
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City | FRIDLEY
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State | MN
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Zip | 55432-5107
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Country | US
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Telephone | 763-571-5497
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Fax |
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Provider Business Mailing Address
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Address Line | 6230 HIGHWAY 65 NE SUITE 105
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City | FRIDLEY
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State | MN
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Zip | 55432-5107
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Country | US
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Telephone | 763-571-5497
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LISA MURRAY PEREZ
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Credential | D.D.S.
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Telephone | 612-414-2182
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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 | D10520
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License Number State | MN
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