Provider Demographics
NPI:1083761449
Name:VENEMAN, DERRICK JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:JOHN
Last Name:VENEMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1774 COPE AVE E STE 110
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2663
Mailing Address - Country:US
Mailing Address - Phone:651-770-7175
Mailing Address - Fax:651-770-6109
Practice Address - Street 1:1774 COPE AVE E STE 110
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2663
Practice Address - Country:US
Practice Address - Phone:651-770-7175
Practice Address - Fax:651-770-6109
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10146122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist