=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538617303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY DILLON MCMAHON D.D.S. M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2016
-----------------------------------------------------
Last Update Date | 10/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1475 WHITE OAK DR
-----------------------------------------------------
City | CHASKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55318-4571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-361-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5009 WILLISTON RD
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-4642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-889-7211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D13664
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------