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General NPI Number Information
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NPI Number | 1407662653
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Entity Type | Organization
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Legal Business Name | STATE OF MINNESOTA - MINNESOTA MANAGEMENT AND BUDGET
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Dates
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Enumeration Date | 12/03/2024
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Last Update Date | 12/03/2024
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Provider Practice Location Address
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Address Line | 2190 WILLIAM AVE
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City | MONTEVIDEO
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State | MN
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Zip | 56265-2273
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Country | US
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Telephone | 651-396-6260
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Fax |
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Provider Business Mailing Address
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Address Line | 5101 MINNEHAHA AVE BLDG 10
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City | MINNEAPOLIS
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State | MN
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Zip | 55417-1647
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MDVA CHIEF OPERATIONS DIRECTOR
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Name | SIMONE RENEE HOGAN
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Credential |
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Telephone | 612-505-4110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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