Provider Demographics
NPI:1679691273
Name:MALTERUD, MARK IVAN (DDS,MAGD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:IVAN
Last Name:MALTERUD
Suffix:
Gender:M
Credentials:DDS,MAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 MOUNT CURVE BLVD.
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1120
Mailing Address - Country:US
Mailing Address - Phone:651-699-2822
Mailing Address - Fax:651-699-3009
Practice Address - Street 1:770 MOUNT CURVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1165
Practice Address - Country:US
Practice Address - Phone:651-699-2822
Practice Address - Fax:651-699-3009
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN94541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice