| NPI | 1467877001 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARY RECK Dental Assistant 651-738-2125 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN 11707) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN 13264) |
| Enumeration Date | 2014-02-19 |
| Last Update Date | 2014-02-19 |