=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770073322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCY HELEN-NEVANEN CORRIN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2018
-----------------------------------------------------
Last Update Date | 05/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 MAIN AVE
-----------------------------------------------------
City | BIGFORK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-743-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50631 NEWBURG LN
-----------------------------------------------------
City | BIGFORK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56628-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-280-7915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D13985
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------