Provider Demographics
NPI:1295867562
Name:MAYTAN, LINDA M (DDS)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:MAYTAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 4TH ST NW
Mailing Address - Street 2:SOUTHERN CITIES CLINIC
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5031
Mailing Address - Country:US
Mailing Address - Phone:507-384-6830
Mailing Address - Fax:651-431-5575
Practice Address - Street 1:400 4TH ST NW
Practice Address - Street 2:SUITE A3A
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5031
Practice Address - Country:US
Practice Address - Phone:507-384-6830
Practice Address - Fax:651-431-5575
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11380122300000X
MA21230122300000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist