Organization
BUCCA DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. EDGAR FERNANDO MANTILLA DDS (CEO)
(612) 724-1717
Entity
Organization
Contact information
Practice address
1508 E LAKE ST, MINNEAPOLIS, MN 55407-1720
(612) 724-1717
(612) 724-3114
Mailing address
1508 E LAKE ST, MINNEAPOLIS, MN 55407-1720
(612) 724-1717
(612) 724-3114
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
D11889
MN
Other
Enumeration date
03/05/2015
Last updated
03/05/2015
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