Provider Demographics
NPI:1649343666
Name:JORGENSON, MICHAEL W (DDS,MS,MBA)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:JORGENSON
Suffix:
Gender:M
Credentials:DDS,MS,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 NORTHWOOD RDG
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1281
Mailing Address - Country:US
Mailing Address - Phone:952-288-7437
Mailing Address - Fax:
Practice Address - Street 1:7700 W. OLD SHAKOPEE RD.
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-5788
Practice Address - Country:US
Practice Address - Phone:952-288-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN83561223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN411381044OtherFED TAX ID
MN5904177OtherMN TAX ID