Provider Demographics
NPI:1740029123
Name:DANG, OMOT
Entity type:Individual
Prefix:
First Name:OMOT
Middle Name:
Last Name:DANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14750 W BURNSVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-3801
Mailing Address - Country:US
Mailing Address - Phone:612-385-1493
Mailing Address - Fax:
Practice Address - Street 1:14750 W BURNSVILLE PKWY
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-3801
Practice Address - Country:US
Practice Address - Phone:612-385-1493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician