=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619532991
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARIA ALEKSEYEVNA GRISHINA DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2019
-----------------------------------------------------
Last Update Date | 05/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1963 ROBERT ST S STE 100
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55118-3942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-724-9689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2732 GRAND AVE S APT 102
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55408-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-889-8611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D14172
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------