Provider Demographics
NPI:1962698340
Name:BOYCHUK, DARRELL G (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:G
Last Name:BOYCHUK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:651-641-6220
Practice Address - Street 1:2500 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1460
Practice Address - Country:US
Practice Address - Phone:651-641-6200
Practice Address - Fax:651-641-6295
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58751122300000X
MN133401223G0001X
MND133401223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice