Provider Demographics
NPI:1902235245
Name:DENTAL SPECIALISTS OF MINNESOTA, PLLC
Entity Type:Organization
Organization Name:DENTAL SPECIALISTS OF MINNESOTA, PLLC
Other - Org Name:THE DENTAL SPECIALIST WOODBURY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:HESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-746-2815
Mailing Address - Street 1:2200 COUNTY ROAD C W
Mailing Address - Street 2:SUITE 2210
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2550
Mailing Address - Country:US
Mailing Address - Phone:651-633-0500
Mailing Address - Fax:651-636-6350
Practice Address - Street 1:10150 CITY WALK DR APT C
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-9270
Practice Address - Country:US
Practice Address - Phone:651-501-0018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty