MEDICARE: DANIELLE MARIE RODGERS RDH, DT

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	124Q00000X	Dental Hygienist	H10120	MN
2	125J00000X	Dental Therapist	DT110	MN

General Provider Information

NPI Number	:	1871156166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE MARIE RODGERS RDH, DT

Provider Business Mailing Address
First Line	:	2900 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1322
Country	:	US
Telephone Number	:	612-823-2080
Fax Number	:	612-259-7850

Provider Business Practice Location Address
First Line	:	2900 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1322
Country	:	US
Telephone Number	:	612-823-2080
Fax Number	:

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

Provider Enumeration Date	:	04/22/2019
Last Update Date	:	04/22/2019

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