Provider Demographics
NPI:1033117551
Name:FOSTER, JEFFREY PAUL (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PAUL
Last Name:FOSTER
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:PAUL
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MSD
Mailing Address - Street 1:11601 MINNETONKA MILLS RD STE B40
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5175
Mailing Address - Country:US
Mailing Address - Phone:952-933-1361
Mailing Address - Fax:952-933-9770
Practice Address - Street 1:11601 MINNETONKA MILLS RD STE B40
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5175
Practice Address - Country:US
Practice Address - Phone:952-933-1361
Practice Address - Fax:952-933-9770
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND107431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7B016FOOtherBCBS OF MN
MN471527262OtherDELTA OF MINNESOTA
PA839878OtherUNITED CONCORDIA MILITARY
MN637214700Medicaid
MN190000653Medicare ID - Type Unspecified
MN637214700Medicaid