NPIMap

Organization Active NPI

Minnesota Periodontal Associates, PA

  • Periodontics
  • White Bear Lake, MN
National Provider Identifier
1508300252
Registry record updated Dec 22, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
License
D13190 Issued in MN
Legal business name
MINNESOTA PERIODONTAL ASSOCIATES, PA
Practice address
4801 Hwy 61 N.
Suite 300
White Bear Lake, MN 55110-2753
Phone
(651) 429-2299
NPI assigned
Dec 15, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 22, 2016

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

Authorized official

Name
Dr. Connie A Lee, D.D.S., M.S.
Title
Periodontist
Phone
(651) 429-2299

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0300X D13190 MN Primary

Addresses

Primary practice location

4801 Hwy 61 N.
Suite 300
White Bear Lake, MN 55110-2753

Mailing address

4801 Hwy 61 N.
Suite 300
White Bear Lake, MN 55110
Phone (651) 429-2299

Other names 1

  • Roger G. Ettel DDS and Associates, PA Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

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": "1481760000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1482364800000",
    "number": "1508300252",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4801 HWY 61 N.",
            "address_2": "SUITE 300",
            "city": "WHITE BEAR LAKE",
            "state": "MN",
            "postal_code": "55110",
            "telephone_number": "651-429-2299"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4801 HWY 61 N.",
            "address_2": "SUITE 300",
            "city": "WHITE BEAR LAKE",
            "state": "MN",
            "postal_code": "551102753",
            "telephone_number": "651-429-2299"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MINNESOTA PERIODONTAL ASSOCIATES, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-12-15",
        "last_updated": "2016-12-22",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "CONNIE",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "PERIODONTIST",
        "authorized_official_telephone_number": "651-429-2299",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.D.S., M.S."
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": "MN",
            "license": "D13190",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Roger G. Ettel DDS and Associates, PA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in White Bear Lake, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2016; 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.