Active NPI
Jacob Lee Dvorak, DT
- Dental Therapist
- Mankato, MN
National Provider Identifier
1174968028
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dental Therapist
- License
- DT23
- Practice address
- 309 Holly LN
Mankato, MN 56001-5422 - Phone
- (507) 388-2120
- NPI assigned
- May 6, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dental Therapist | 125J00000X | DT23 | MN | Primary |
Addresses
Primary practice location
309 Holly LN
Mankato, MN 56001-5422
Mailing address
2018 Meadow St
Cologne, MN 55322-9069
Phone (952) 836-6805
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DT23 | MN | MD | Dental Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1367798400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1367798400000",
"number": "1174968028",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2018 MEADOW ST",
"city": "COLOGNE",
"state": "MN",
"postal_code": "553229069",
"telephone_number": "952-836-6805"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "309 HOLLY LN",
"city": "MANKATO",
"state": "MN",
"postal_code": "560015422",
"telephone_number": "507-388-2120"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DVORAK",
"first_name": "JACOB",
"middle_name": "LEE",
"credential": "DT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2013-05-06",
"last_updated": "2013-05-06",
"status": "A"
},
"taxonomies": [
{
"code": "125J00000X",
"taxonomy_group": "",
"desc": "Dental Therapist",
"state": "MN",
"license": "DT23",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Mankato, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.