MEDICARE: RONALD L. KING, D.D.S.

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	D7821	MN

General Provider Information

NPI Number	:	1497944516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RONALD L. KING, D.D.S.

Provider Business Mailing Address
First Line	:	6100 EXCELSIOR BLVD
Second Line	:	SUITE EAST
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2720
Country	:	US
Telephone Number	:	952-929-4545
Fax Number	:	952-929-4592

Provider Business Practice Location Address
First Line	:	6100 EXCELSIOR BLVD
Second Line	:	SUITE EAST
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2720
Country	:	US
Telephone Number	:	952-929-4545
Fax Number	:	952-929-4592

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RONALD LEE KING
Credential	:	D.D.S.
Telephone Number	:	952-929-4545

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	10/16/2007

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