| NPI | 1134547730 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RUSSELL ALLEN DYLLA Owner 952-922-6949 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MN D12016) |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2014-04-01 |