Basic Information
| Provider Information | |||||||||
| NPI: | 1871983478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAKOTA MEDICAL CLINIC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3408 DAKOTA AVE S | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554162312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529241053 | ||||||||
| FaxNumber: | 9529240254 | ||||||||
| Practice Location | |||||||||
| Address1: | 3408 DAKOTA AVE S | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554162312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529241053 | ||||||||
| FaxNumber: | 9529240254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOLE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9529241053 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 29325 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.