MEDICARE: WEST RIVER DENTAL CARE

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	1223G0001X	General Practice Dentistry	10636	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7B839SK	OTHER	MN	BCBS PROVIDER #

General Provider Information

NPI Number	:	1033223581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST RIVER DENTAL CARE

Provider Business Mailing Address
First Line	:	4103 E LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2259
Country	:	US
Telephone Number	:	612-721-2424
Fax Number	:	612-721-3054

Provider Business Practice Location Address
First Line	:	4103 E LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2259
Country	:	US
Telephone Number	:	612-721-2424
Fax Number	:	612-721-3054

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL PAUL SKADRON
Credential	:	D.D.S.
Telephone Number	:	612-721-2424

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	08/22/2020

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Directions to “WEST RIVER DENTAL CARE ” Practice Location

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