Provider Demographics
NPI:1760035141
Name:PATRICK, EMMANUEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:J
Last Name:PATRICK
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 1:15546 OMEGA TRL SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2033
Mailing Address - Country:US
Mailing Address - Phone:952-807-2248
Mailing Address - Fax:
Practice Address - Street 1:1125 SILVER LAKE RD NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6324
Practice Address - Country:US
Practice Address - Phone:651-842-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND142961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice