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General NPI Number Information
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NPI Number | 1679947287
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Entity Type | Organization
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Legal Business Name | PURE DENTAL
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Dates
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Enumeration Date | 11/19/2015
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Last Update Date | 11/19/2015
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Provider Practice Location Address
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Address Line | 6230 10TH ST N SUITE #520
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City | OAKDALE
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State | MN
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Zip | 55128-6158
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Country | US
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Telephone | 651-731-3064
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Fax | 651-731-9340
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Provider Business Mailing Address
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Address Line | 6230 10TH ST N SUITE #520
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City | OAKDALE
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State | MN
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Zip | 55128-6158
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Country | US
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Telephone | 651-731-3064
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Fax | 651-731-9340
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Authorized Official
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Title or Position | DENTIST
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Name | DR. AMY TRUONG
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Credential | DDS
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Telephone | 651-329-5141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D12647
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License Number State | MN
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