| NPI | 1821079583 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TRACEY M KOCTT Practice Manager 651-389-1133 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN 8109) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN 9975) |
| Enumeration Date | 2005-11-09 |
| Last Update Date | 2020-08-22 |