=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518231596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODBURY DENTAL ARTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2012
-----------------------------------------------------
Last Update Date | 10/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 237 RADIO DR STE 110
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-4478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-436-7559
-----------------------------------------------------
Fax | 651-436-7553
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 237 RADIO DR STE 110
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-4478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-436-7559
-----------------------------------------------------
Fax | 651-436-7553
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DDS
-----------------------------------------------------
Name | MARKO KAMEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-808-7731
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------