MEDICARE: GROVE DENTIST PA

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	D11844	MN

General Provider Information

NPI Number	:	1326481284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROVE DENTIST PA

Provider Business Mailing Address
First Line	:	13649 GROVE DR
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-4405
Country	:	US
Telephone Number	:	763-420-8038
Fax Number	:	763-494-4222

Provider Business Practice Location Address
First Line	:	13649 GROVE DR
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-4405
Country	:	US
Telephone Number	:	763-420-8038
Fax Number	:	763-494-4222

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RENY CHACKO
Credential	:
Telephone Number	:	651-308-2804

Provider Enumeration Date	:	04/10/2013
Last Update Date	:	04/10/2013

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