NPIMap

Organization Active NPI

Southdale Periodontics, PLLC

  • Periodontics
  • Edina, MN
National Provider Identifier
1134547730
Registry record updated Apr 1, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
License
D12016 Issued in MN
Legal business name
SOUTHDALE PERIODONTICS, PLLC
Practice address
6545 France Ave S
Suite 190
Edina, MN 55435-2131
Phone
(952) 922-6949
Fax
(952) 922-9287
NPI assigned
Apr 1, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 1, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Russell Allen Dylla, D.D.S.NPI 1710180294
Title
Owner
Phone
(952) 922-6949

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0300X D12016 MN Primary

Addresses

Primary practice location

6545 France Ave S
Suite 190
Edina, MN 55435-2131

Mailing address

6545 France Ave S
Suite 190
Edina, MN 55435-2131
Phone (952) 922-6949

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1396310400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1396310400000",
    "number": "1134547730",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6545 FRANCE AVE S",
            "address_2": "SUITE 190",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554352131",
            "telephone_number": "952-922-6949",
            "fax_number": "952-922-9287"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6545 FRANCE AVE S",
            "address_2": "SUITE 190",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554352131",
            "telephone_number": "952-922-6949",
            "fax_number": "952-922-9287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHDALE PERIODONTICS, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-01",
        "last_updated": "2014-04-01",
        "status": "A",
        "authorized_official_last_name": "DYLLA",
        "authorized_official_first_name": "RUSSELL",
        "authorized_official_middle_name": "ALLEN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "952-922-6949",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.D.S."
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": "MN",
            "license": "D12016",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Edina, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.