=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952467615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL HEALTH CARE CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 09/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 EAST 66TH STREET
-----------------------------------------------------
City | RICHFIELD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55423-2722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-861-7109
-----------------------------------------------------
Fax | 612-253-7422
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1717 EAST 66TH STREET
-----------------------------------------------------
City | RICHFIELD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55423-2722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-861-7109
-----------------------------------------------------
Fax | 612-253-7422
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST CORP PRESIDENT
-----------------------------------------------------
Name | DR. JOHN MICHAEL WOELL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 612-861-7109
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D11737
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D8740
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D8581
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D11577
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------