Individual
PHONSUDA CHANTHAVISOUK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RDH, MDT
Contact information
Practice address
728 E HENNEPIN AVE, MINNEAPOLIS, MN 55414-1126
(612) 746-1530
Mailing address
6145 14TH AVE S, MINNEAPOLIS, MN 55423-1728
(612) 961-9886
Taxonomy
Speciality
Code
Description
License number
State
124Q00000X
Dental Hygienist
H11002
MN
125J00000X
Dental Therapist
Primary
DT137
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
DT137
—
MN
Enumeration date
05/11/2021
Last updated
08/08/2023
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