=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629885884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHSTAR DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2024
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3930 SUNNYSIDE RD
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55424-1211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-877-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 866 TRENTON LN N
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55441-4497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-877-2288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | DR. D GRANT LEWIS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 412-877-2288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------