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General NPI Number Information
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NPI Number | 1538112180
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Entity Type | Organization
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Legal Business Name | CHANHASSEN DENTAL
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Dates
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Enumeration Date | 05/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 480 W 78TH ST SUITE #116
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City | CHANHASSEN
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State | MN
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Zip | 55317-4527
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Country | US
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Telephone | 952-934-3383
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Fax | 952-934-6668
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Provider Business Mailing Address
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Address Line | PO BOX 189
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City | CHANHASSEN
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State | MN
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Zip | 55317-0189
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Country | US
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Telephone | 952-934-3383
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Fax | 952-934-6668
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MRS. JOLEEN KAY HALL
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Credential |
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Telephone | 952-934-3383
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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 | 10519
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 7951
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License Number State | MN
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