MEDICARE: DENTISTS OF HIGHLAND PARK, PC

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

General Provider Information

NPI Number	:	1659881944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTS OF HIGHLAND PARK, PC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	303-952-0892

Provider Business Practice Location Address
First Line	:	2096 FORD PKWY
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1813
Country	:	US
Telephone Number	:	651-237-9913
Fax Number	:

Authorized Official
Title or Position	:	DMD/OWNER
Name	:	ROBERT J SEYMOUR
Credential	:
Telephone Number	:	651-237-9913

Provider Enumeration Date	:	10/02/2017
Last Update Date	:	10/02/2017

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