# DENTAL SPECIALIST OF MINNESOTA, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** The Dental Specialist Deephaven
- **Organization subpart:** No

## Provider details

- **NPI number:** 1568071199
- **Authorized official:** SHANNON HESSE (CREDENTIALING SPECIALIST)
- **Authorized official phone:** (651) 746-2815

## Contact information

- **Practice address:** 18258 MINNETONKA BLVD STE 100, WAYZATA, MN 55391-3324
- **Practice address phone:** (952) 926-2761
- **Mailing address:** 2200 COUNTY ROAD C W STE 2210, ROSEVILLE, MN 55113-2551
- **Mailing address phone:** (651) 746-2815

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223E0200X | Endodontics | — | NULL | — |
| 1223E0200X | Endodontics | — | — | — |
| 1223P0221X | Pediatric Dentistry | — | NULL | — |
| 1223P0221X | Pediatric Dentistry | — | — | — |
| 1223P0300X | Periodontics | — | NULL | — |
| 1223P0300X | Periodontics | — | — | — |
| 1223P0700X | Prosthodontics | — | NULL | — |
| 1223P0700X | Prosthodontics | — | — | — |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | NULL | Yes |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | — | Yes |

## Other

- **Enumeration date:** 07/29/2020
- **Last updated:** 07/29/2020