=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891833059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT PLAINS DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W 79TH ST
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-934-7987
-----------------------------------------------------
Fax | 952-934-5732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 W 79TH ST
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-934-7987
-----------------------------------------------------
Fax | 952-934-5732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MARK W DAVIES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 952-934-7987
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D11876
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------