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General NPI Number Information
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NPI Number | 1841317732
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Entity Type | Organization
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Legal Business Name | MARK I. MALTERUD, D.D.S., P.A.
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 770 MOUNT CURVE BLVD
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City | SAINT PAUL
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State | MN
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Zip | 55116-1165
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Country | US
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Telephone | 651-699-2822
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Fax | 651-699-3009
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Provider Business Mailing Address
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Address Line | 770 MOUNT CURVE BLVD
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City | SAINT PAUL
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State | MN
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Zip | 55116-1165
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Country | US
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Telephone | 651-699-2822
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Fax | 651-699-3009
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Authorized Official
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Title or Position | OWNER
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Name | MARK IVAN MALTERUD
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Credential | D.D.S.,M.A.G.D.
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Telephone | 651-699-2822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 9454
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License Number State | MN
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