| NPI | 1801566740 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHAD HENDRICKS Credentialing Manager 612-859-0444 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry |
| Enumeration Date | 2021-09-13 |
| Last Update Date | 2021-09-13 |