Provider Demographics
NPI:1104004993
Name:ODEGAARD, DANIEL O (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:O
Last Name:ODEGAARD
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 1:825 NICOLLET MALL
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402
Mailing Address - Country:US
Mailing Address - Phone:612-332-2618
Mailing Address - Fax:
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 1001
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402
Practice Address - Country:US
Practice Address - Phone:612-332-2618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND78361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN495-717-200OtherMINN MEDICAL ASSISTANCE