MEDICARE: DR. CARMEN REAL DDS

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	122300000X	Dentist	FF24	MN

General Provider Information

NPI Number	:	1588987135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARMEN REAL DDS

Provider Business Mailing Address
First Line	:	8301 W LAKE CT
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-8514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8301 W LAKE CT
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-8514
Country	:	US
Telephone Number	:	952-270-5553
Fax Number	:

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

Provider Enumeration Date	:	03/11/2010
Last Update Date	:	03/11/2010

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