MEDICARE: MENON PERIODONTICS AND IMPLANTS, LLC

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	1223P0300X	Periodontics	S30	MN

General Provider Information

NPI Number	:	1225425309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENON PERIODONTICS AND IMPLANTS, LLC

Provider Business Mailing Address
First Line	:	1880 LIVINGSTON AVE
Second Line	:	SUITE # 101
City	:	WEST SAINT PAUL
State	:	MN
Zip	:	55118-3425
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1880 LIVINGSTON AVE
Second Line	:	SUITE # 101
City	:	WEST SAINT PAUL
State	:	MN
Zip	:	55118-3425
Country	:	US
Telephone Number	:	651-646-1318
Fax Number	:

Authorized Official
Title or Position	:	PERIODONTIST
Name	:	DR. HEMA V MENON
Credential	:	BDS, MS
Telephone Number	:	651-646-1318

Provider Enumeration Date	:	04/16/2015
Last Update Date	:	04/16/2015

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