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General NPI Number Information
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NPI Number | 1730655242
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Entity Type | Organization
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Legal Business Name | ROUND LAKE FAMILY DENTISTRY, PLLC
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Dates
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Enumeration Date | 10/23/2018
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Last Update Date | 10/23/2018
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Provider Practice Location Address
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Address Line | 13841 ROUND LAKE BLVD NW
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City | ANDOVER
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State | MN
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Zip | 55304-3664
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Country | US
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Telephone | 763-427-0285
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Fax |
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Provider Business Mailing Address
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Address Line | 7493 147TH ST W STE 100
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City | APPLE VALLEY
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State | MN
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Zip | 55124-7570
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Country | US
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Telephone | 952-432-7145
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | PHILLIP ZHAN
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Credential | DDS
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Telephone | 612-308-9416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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