Provider Demographics
NPI:1942424841
Name:RESTAD, DAWN RENEE (IBO)
Entity Type:Individual
Prefix:MS
First Name:DAWN
Middle Name:RENEE
Last Name:RESTAD
Suffix:
Gender:F
Credentials:IBO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-1601
Mailing Address - Country:US
Mailing Address - Phone:218-205-4330
Mailing Address - Fax:218-346-1237
Practice Address - Street 1:450 1ST AVE S
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1601
Practice Address - Country:US
Practice Address - Phone:218-205-4330
Practice Address - Fax:218-346-1237
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0199999OtherMEDICA PROVIDER NUMBER