=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750465753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HANSON AND FONKERT DENTAL CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 SOUTH FIRST STREET SUITE 3
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-3595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-235-2780
-----------------------------------------------------
Fax | 320-235-8838
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 SOUTH FIRST STREET SUITE 3
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-3595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-235-2780
-----------------------------------------------------
Fax | 320-235-8838
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. TOMI JEAN PIRROTTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-235-2780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------