Provider Demographics
NPI:1972656569
Name:KUMAR, PREM (DDS)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:
Last Name:KUMAR
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 1:11301 FOUNTAINS DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7200
Mailing Address - Country:US
Mailing Address - Phone:763-762-7177
Mailing Address - Fax:763-762-7177
Practice Address - Street 1:3803 SILVER LAKE RD NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-4574
Practice Address - Country:US
Practice Address - Phone:612-782-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN937605400OtherMEDICAL ASSISTANCE NUMBER