=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891179958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERRY DENTAL, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2015
-----------------------------------------------------
Last Update Date | 07/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 HIAWATHA DR E
-----------------------------------------------------
City | WABASHA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55981-1733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-565-2888
-----------------------------------------------------
Fax | 651-565-2882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 HIAWATHA DR E
-----------------------------------------------------
City | WABASHA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55981-1733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-565-2888
-----------------------------------------------------
Fax | 651-565-2882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. SHARON A KENNEBECK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-565-2888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 09963
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 13557
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------