=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831899046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN F. REARDON DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2023
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 MAIN ST N STE 111
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55082-5054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-439-6125
-----------------------------------------------------
Fax | 651-439-0038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 MAIN ST N STE 111
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55082-5054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-439-6125
-----------------------------------------------------
Fax | 651-439-0038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN FORAN REARDON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 651-216-2072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------