Facts
- Status
- A
- Credential
- D.D.S.
- Type
- Individual
- Enumeration date
- 2012-11-15
- Last updated
- 2012-11-15
Specialties
Licenses
- License MN
- 9644
Location
- Practice location
- 604 SECOND STREET
- City
- JACKSON MN
- Postal code
- 56143
- Phone
- 507-847-3910
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.