Provider Demographics
NPI:1124896816
Name:FERN, MADELEINNE
Entity type:Individual
Prefix:
First Name:MADELEINNE
Middle Name:
Last Name:FERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7770 DELL ROAD, SUITE #110
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-2809
Mailing Address - Country:US
Mailing Address - Phone:952-294-3575
Mailing Address - Fax:
Practice Address - Street 1:7770 DELL ROAD, SUITE #110
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-2809
Practice Address - Country:US
Practice Address - Phone:952-294-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND150231223E0200X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223E0200XDental ProvidersDentistEndodontics