Khashayar Khodadoustan, DDS
Individual provider Active NPI General Practice Dentistry · Glencoe, MN
NPI 1598505083 · NPPES record last updated May 30, 2024
Key facts
- NPI
- 1598505083
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- D15073 (MN)
- Practice address
- 1126 Ives Ave N
Glencoe, MN 55336-2226 - Phone
- (320) 864-3215
- Fax
- (320) 864-2768
- NPI assigned
- May 30, 2024
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20250604003026 | MN | Order and Referring Only - Dentist |
1951810563 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D15073 | MN | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Gwen Regnier DMD PLLC | Current |
Accepting new patients |
Locations
1126 Ives Ave N
Glencoe, MN 55336
Phone (320) 864-3215
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | D15073 | MN | Yes |
Addresses
Primary practice location
1126 Ives Ave N
Glencoe, MN 55336-2226
Mailing address
1738 Palisade Cir
Eagan, MN 55122-1721
Phone (651) 757-0940
Other providers in Glencoe, MN
- Laura Junker
- Alexandria Campbell Kalina
- Jennifer Keenan
- Jennifer Keltgen
- Caitlin Rose Kemp
- Kari N Knodel-Vettel
- Shawn Donald Knorr
- Kristine Leonard Knudten
- Jane J. Kokesh
- Kurt Donald Kramer
All providers in Glencoe, MN · General Practice Dentistry in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 30, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.