Provider Demographics
NPI:1407536196
Name:MNPL02 PLLC
Entity Type:Organization
Organization Name:MNPL02 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSSA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-349-8564
Mailing Address - Street 1:14300 CLAY TERRACE BLVD STE 249
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3636
Mailing Address - Country:US
Mailing Address - Phone:317-502-0717
Mailing Address - Fax:
Practice Address - Street 1:1099 HELMO AVE N STE 110
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6034
Practice Address - Country:US
Practice Address - Phone:651-372-3300
Practice Address - Fax:651-337-8305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty