Provider Demographics
NPI:1124544895
Name:MSP DENTISTRY INC
Entity Type:Organization
Organization Name:MSP DENTISTRY INC
Other - Org Name:TWIN CITIES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:
Authorized Official - First Name:MAJID
Authorized Official - Middle Name:
Authorized Official - Last Name:FEHRESTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-421-7900
Mailing Address - Street 1:13650 HANSON BLVD.
Mailing Address - Street 2:SUITE #110
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304
Mailing Address - Country:US
Mailing Address - Phone:763-421-7900
Mailing Address - Fax:763-421-7916
Practice Address - Street 1:13650 HANSON BLVD.
Practice Address - Street 2:SUITE #110
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304
Practice Address - Country:US
Practice Address - Phone:763-421-7900
Practice Address - Fax:763-421-7916
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MSP DENTISTRY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12034305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization