=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780902080
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBBINSDALE DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2010
-----------------------------------------------------
Last Update Date | 05/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4125 LAKELAND AVE N SUITE 100
-----------------------------------------------------
City | ROBBINSDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55422-1852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-537-5123
-----------------------------------------------------
Fax | 763-533-2034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 CAPRIOLE DR
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55340-9494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-865-5185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RUPAM KADEMANI
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 763-537-5123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D12023
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------