=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710624374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAR MENG XIONG RDH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2022
-----------------------------------------------------
Last Update Date | 05/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 636 BROADWAY ST NE
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55413-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-238-0217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3305 199TH AVE NE
-----------------------------------------------------
City | EAST BETHEL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55011-9751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-236-3825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | H9745
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------