NPIMap

Organization Active NPI

Moore Lake Dental

  • Dentist
  • Fridley, MN
National Provider Identifier
1386035590
Registry record updated Feb 10, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
D10520 Issued in MN
Legal business name
MOORE LAKE DENTAL
Practice address
6230 Highway 65 NE
Suite 105
Fridley, MN 55432-5107
Phone
(763) 571-5497
NPI assigned
Feb 10, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 10, 2015

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

Authorized official

Name
Dr. Lisa Murray Perez, D.D.S.
Title
Owner
Phone
(612) 414-2182

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X SINGLE SPECIALTY GROUP 122300000X D10520 MN Primary

Addresses

Primary practice location

6230 Highway 65 NE
Suite 105
Fridley, MN 55432-5107

Mailing address

6230 Highway 65 NE
Suite 105
Fridley, MN 55432-5107
Phone (763) 571-5497

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

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": "1423526400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1423526400000",
    "number": "1386035590",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6230 HIGHWAY 65 NE",
            "address_2": "SUITE 105",
            "city": "FRIDLEY",
            "state": "MN",
            "postal_code": "554325107",
            "telephone_number": "763-571-5497"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6230 HIGHWAY 65 NE",
            "address_2": "SUITE 105",
            "city": "FRIDLEY",
            "state": "MN",
            "postal_code": "554325107",
            "telephone_number": "763-571-5497"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOORE LAKE DENTAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-02-10",
        "last_updated": "2015-02-10",
        "status": "A",
        "authorized_official_last_name": "PEREZ",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "MURRAY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "612-414-2182",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.D.S."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "MN",
            "license": "D10520",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fridley, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2015; 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.