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General NPI Number Information
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NPI Number | 1407536196
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Entity Type | Organization
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Legal Business Name | MNPL02 PLLC
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Dates
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Enumeration Date | 07/19/2023
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Last Update Date | 07/19/2023
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Provider Practice Location Address
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Address Line | 1099 HELMO AVE N STE 110
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City | OAKDALE
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State | MN
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Zip | 55128-6034
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Country | US
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Telephone | 651-372-3300
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Fax | 651-337-8305
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Provider Business Mailing Address
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Address Line | 14300 CLAY TERRACE BLVD STE 249
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City | CARMEL
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State | IN
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Zip | 46032-3636
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Country | US
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Telephone | 317-502-0717
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | NICHOLAS BUSSA
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Credential | DDS
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Telephone | 218-349-8564
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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 |
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License Number State |
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