MEDICARE: NICOLLET MALL DENTAL ARTS PLLC

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

General Provider Information

NPI Number	:	1528695178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLLET MALL DENTAL ARTS PLLC

Provider Business Mailing Address
First Line	:	2836 COLFAX AVE S APT E436
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-4855
Country	:	US
Telephone Number	:	218-791-5380
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 NICOLLET MALL STE 1737
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2704
Country	:	US
Telephone Number	:	612-332-1164
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NORAH HOVERSON
Credential	:	DDS
Telephone Number	:	218-791-5380

Provider Enumeration Date	:	03/24/2020
Last Update Date	:	03/24/2020

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