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General NPI Number Information
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NPI Number | 1407008477
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Entity Type | Organization
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Legal Business Name | DYLLA-JENSEN PERIODONTICS PLLC
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Dates
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Enumeration Date | 10/21/2008
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Last Update Date | 10/21/2008
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Provider Practice Location Address
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Address Line | 6545 FRANCE AVE S
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City | EDINA
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State | MN
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Zip | 55435-2131
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Country | US
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Telephone | 952-922-6949
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Fax | 952-922-9287
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Provider Business Mailing Address
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Address Line | 6545 FRANCE AVE S
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City | EDINA
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State | MN
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Zip | 55435-2131
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Country | US
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Telephone | 952-922-6949
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Fax |
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Authorized Official
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Title or Position | D.D.S.
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Name | DR. RUSSELL DYLLA
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Credential | D.D.S.
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Telephone | 952-922-6949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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