Individual
MARY K LACONIC
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
5200 DOUGLAS DR N, CRYSTAL, MN 55429-3104
(763) 537-3213
(763) 537-6732
Mailing address
5200 DOUGLAS DR N, CRYSTAL, MN 55429-3104
(763) 537-3213
(763) 537-6732
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1674
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
749823300
—
MN
Enumeration date
06/08/2005
Last updated
06/29/2011
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