MEDICARE: MARY OWEN 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	1223G0001X	General Practice Dentistry	10075	MN

General Provider Information

NPI Number	:	1548230709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY OWEN D.D.S.

Provider Business Mailing Address
First Line	:	14418 EXCELSIOR BLVD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5820
Country	:	US
Telephone Number	:	952-935-5212
Fax Number	:

Provider Business Practice Location Address
First Line	:	14418 EXCELSIOR BLVD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5820
Country	:	US
Telephone Number	:	952-935-5212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	04/06/2015

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