MEDICARE: MENDOTA HEIGHTS DENTAL CENTER

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	9102	MN

General Provider Information

NPI Number	:	1730351214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENDOTA HEIGHTS DENTAL CENTER

Provider Business Mailing Address
First Line	:	880 SIBLEY MEMORIAL HWY
Second Line	:
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55118-1736
Country	:	US
Telephone Number	:	651-455-4223
Fax Number	:	651-455-0107

Provider Business Practice Location Address
First Line	:	880 SIBLEY MEMORIAL HWY
Second Line	:
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55118-1736
Country	:	US
Telephone Number	:	651-455-4223
Fax Number	:	651-455-0107

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	PAM J MAXA
Credential	:
Telephone Number	:	651-455-4223

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	03/25/2008

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