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General NPI Number Information
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NPI Number | 1992818751
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Entity Type | Organization
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Legal Business Name | CHAMPLIN FAMILY DENTAL PA
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Dates
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Enumeration Date | 08/16/2006
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Last Update Date | 04/22/2015
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Provider Practice Location Address
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Address Line | 12233 CHAMPLIN DRIVE
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City | CHAMPLIN
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State | MN
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Zip | 55316
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Country | US
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Telephone | 763-323-0678
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Fax | 763-323-9102
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Provider Business Mailing Address
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Address Line | 12233 CHAMPLIN DRIVE
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City | CHAMPLIN
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State | MN
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Zip | 55316
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Country | US
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Telephone | 763-323-0678
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Fax | 763-323-9102
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KRISTA SUSAN BAUER
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Credential | DDS
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Telephone | 763-323-0678
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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 | 11195
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 9624
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License Number State | MN
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