Provider Demographics
NPI:1780794115
Name:MAKI, DAVID ROBERT
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ROBERT
Last Name:MAKI
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 1:1790 7TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-3419
Mailing Address - Country:US
Mailing Address - Phone:651-735-0595
Mailing Address - Fax:
Practice Address - Street 1:1790 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-3419
Practice Address - Country:US
Practice Address - Phone:651-735-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND135901223G0001X, 1223G0001X
OK59121223G0001X
CO96421223G0001X
WY12431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200090510AMedicaid