Provider Demographics
NPI:1164504437
Name:MARDELL, MICHAEL C (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:MARDELL
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 1:14470 CAMEO AVE W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-4025
Mailing Address - Country:US
Mailing Address - Phone:651-423-2259
Mailing Address - Fax:
Practice Address - Street 1:14470 CAMEO AVE W
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-4025
Practice Address - Country:US
Practice Address - Phone:651-423-2259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND78831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1255369278OtherCORPORATION NPI