MEDICARE: TOWN DENTAL, PA

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1962460881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOWN DENTAL, PA

Provider Business Mailing Address
First Line	:	425 2ND ST
Second Line	:
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-2038
Country	:	US
Telephone Number	:	952-474-6133
Fax Number	:	952-474-7361

Provider Business Practice Location Address
First Line	:	425 2ND ST
Second Line	:
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-2038
Country	:	US
Telephone Number	:	952-474-6133
Fax Number	:	952-474-7361

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. BECKY ROSE GRIMM
Credential	:
Telephone Number	:	952-474-6133

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	08/22/2020

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Directions to “TOWN DENTAL, PA ” Practice Location

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