MEDICARE: METROPOLITAN PERIODONTISTS

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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1669199741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METROPOLITAN PERIODONTISTS

Provider Business Mailing Address
First Line	:	825 NICOLLET MALL
Second Line	:	STE. 210
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2618
Country	:	US
Telephone Number	:	612-332-0869
Fax Number	:	612-332-2891

Provider Business Practice Location Address
First Line	:	825 NICOLLET MALL
Second Line	:	STE. 210
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2618
Country	:	US
Telephone Number	:	612-332-0869
Fax Number	:	612-332-2891

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MARK WILSON
Credential	:	D.D.S.
Telephone Number	:	612-332-0869

Provider Enumeration Date	:	10/20/2022
Last Update Date	:	10/20/2022

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Directions to “METROPOLITAN PERIODONTISTS ” Practice Location

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