MEDICARE: DR. RICHARD JOSEPH PROKOSCH

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	7345MN	MN

General Provider Information

NPI Number	:	1831286137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD JOSEPH PROKOSCH

Provider Business Mailing Address
First Line	:	1736 EAST COPE AVE
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-2610
Country	:	US
Telephone Number	:	651-770-3831
Fax Number	:	651-770-9645

Provider Business Practice Location Address
First Line	:	1736 EAST COPE AVE
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-2610
Country	:	US
Telephone Number	:	651-770-3831
Fax Number	:	651-770-9645

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

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	07/08/2007

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