MEDICARE: MANITOU DENTAL CARE LTD

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	:	1902234743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANITOU DENTAL CARE LTD

Provider Business Mailing Address
First Line	:	2189 3RD ST
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3214
Country	:	US
Telephone Number	:	651-429-9221
Fax Number	:	651-429-4320

Provider Business Practice Location Address
First Line	:	2189 3RD ST
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3214
Country	:	US
Telephone Number	:	651-429-9221
Fax Number	:	651-429-4320

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. SUZANNE MARIE KAPPEL-GEIB
Credential	:	D.D.S.
Telephone Number	:	651-429-9221

Provider Enumeration Date	:	10/14/2013
Last Update Date	:	10/14/2013

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