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General NPI Number Information
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NPI Number | 1689017261
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Entity Type | Individual
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Provider Name | CORISSA JULIE FLAGG RDH
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Gender | Female
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Dates
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Enumeration Date | 04/12/2013
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Last Update Date | 04/12/2013
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Provider Practice Location Address
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Address Line | 1700 HIGHWAY 36 W STE 860
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City | SAINT PAUL
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State | MN
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Zip | 55113-4034
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Country | US
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Telephone | 651-778-9911
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Fax |
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Provider Business Mailing Address
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Address Line | 11321 IBIS ST NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-3750
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Country | US
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Telephone | 763-238-2136
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | H8180
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License Number State | MN
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