Provider Demographics
NPI:1083676944
Name:DANIEL O ODEGAARD DDS PA
Entity Type:Organization
Organization Name:DANIEL O ODEGAARD DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:ODEGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-332-2618
Mailing Address - Street 1:825 NICOLLET MALL
Mailing Address - Street 2:STE 1001
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2614
Mailing Address - Country:US
Mailing Address - Phone:612-332-2618
Mailing Address - Fax:612-332-5972
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:STE 1001
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2614
Practice Address - Country:US
Practice Address - Phone:612-332-2618
Practice Address - Fax:612-332-5972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND7836122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty