MEDICARE: DENTAL SPECIALISTS OF MINNESOTA, PLLC

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1902235245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL SPECIALISTS OF MINNESOTA, PLLC

Provider Business Mailing Address
First Line	:	2200 COUNTY ROAD C W
Second Line	:	SUITE 2210
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-2550
Country	:	US
Telephone Number	:	651-633-0500
Fax Number	:	651-636-6350

Provider Business Practice Location Address
First Line	:	10150 CITY WALK DR APT C
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55129-9270
Country	:	US
Telephone Number	:	651-501-0018
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	SHANNON HESSE
Credential	:
Telephone Number	:	651-746-2815

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	10/28/2020

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