Individual
PA NHIA HER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
5700 BOTTINEAU BLVD STE 270, CRYSTAL, MN 55429-2671
(763) 200-8952
Mailing address
9465 189TH AVE NE, COLUMBUS, MN 55025-8320
(651) 285-5652
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D14725
MN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/15/2022
Last updated
05/25/2022
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