MEDICARE: COMMUNITY DENTAL CARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center
2	122300000X	Dentist	460668000	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003886383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY DENTAL CARE INC

Provider Business Mailing Address
First Line	:	1670 BEAM AVE
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109
Country	:	US
Telephone Number	:	651-925-8400
Fax Number	:	651-925-8439

Provider Business Practice Location Address
First Line	:	600 CARLTON STREET N
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55119
Country	:	US
Telephone Number	:	651-774-2959
Fax Number	:	651-774-1997

Authorized Official
Title or Position	:	HR DIRECTOR
Name	:	DR. KORI C CARLSON
Credential	:
Telephone Number	:	651-925-8427

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	07/24/2025

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Directions to “COMMUNITY DENTAL CARE INC ” Practice Location

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