| NPI | 1225629017 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LISA BJORKMAN Director Provider Enrollment 952-883-7469 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery |
| Additional Taxonomies | 1223E0200X Dentist Endodontics |
| 1223P0300X Dentist Periodontics | |
| 1223P0700X Dentist Prosthodontics | |
| Enumeration Date | 2021-02-03 |
| Last Update Date | 2021-02-03 |