| NPI | 1104057975 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CARYL LEACH Administrator 952-903-5000 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery |
| Enumeration Date | 2009-07-28 |
| Last Update Date | 2009-07-28 |