Provider Demographics
NPI:1417002304
Name:SORENSON, RICHARD ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:SORENSON
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 1:4454 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3522
Mailing Address - Country:US
Mailing Address - Phone:612-823-6262
Mailing Address - Fax:612-823-6783
Practice Address - Street 1:4454 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3522
Practice Address - Country:US
Practice Address - Phone:612-823-6262
Practice Address - Fax:612-823-6783
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND76051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice