=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740510510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY TEETH CLUB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2009
-----------------------------------------------------
Last Update Date | 12/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13410 CANALVILLE LN
-----------------------------------------------------
City | GRASSTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55030-2162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-894-4391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13410 CANALVILLE LN
-----------------------------------------------------
City | GRASSTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55030-2162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-894-4391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COLLABORATIVE DENTAL HYGIENIST
-----------------------------------------------------
Name | MRS. REBECCA L FAHNING
-----------------------------------------------------
Credential | RDH,BS
-----------------------------------------------------
Telephone | 651-894-4391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | H5749
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------