Basic Information
| Provider Information | |||||||||
| NPI: | 1477530996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHOWALTER | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6465 WAYZATA BLVD | ||||||||
| Address2: | STE 315 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529937169 | ||||||||
| FaxNumber: | 9529930300 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 CENTRAL AVE N | ||||||||
| Address2: | STE 228 PARK NICOLLET CLINIC - WAYZAT | ||||||||
| City: | WAYZATA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529938250 | ||||||||
| FaxNumber: | 9529938276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39874 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.