| NPI | 1760013015 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHANNON HESSE Credentialing Specialist 651-746-2815 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center Dental |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry |
| 1223P0106X Dentist Oral and Maxillofacial Pathology | |
| 1223E0200X Dentist Endodontics | |
| 1223P0300X Dentist Periodontics | |
| 1223P0700X Dentist Prosthodontics | |
| Enumeration Date | 2020-01-27 |
| Last Update Date | 2020-01-28 |