Active NPI
Corine Nicole McLellan, DDS
- General Practice Dentistry
- Blaine, MN
National Provider Identifier
1629137500
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- D11538
- Practice address
- 12904 Central Ave NE
Blaine, MN 55434-4147 - Phone
- (763) 755-1330
- Fax
- (763) 755-4305
- NPI assigned
- Dec 7, 2006
- Sex
- Female
- 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 |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | D11538 | MN | Primary |
Addresses
Primary practice location
12904 Central Ave NE
Blaine, MN 55434-4147
Mailing address
11716 Arnold Palmer TRL
Blaine, MN 55449-4520
Phone (763) 717-0007
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 |
|---|---|---|---|
| D11538 | MN | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1165449600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1629137500",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11716 ARNOLD PALMER TRL",
"city": "BLAINE",
"state": "MN",
"postal_code": "554494520",
"telephone_number": "763-717-0007"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12904 CENTRAL AVE NE",
"city": "BLAINE",
"state": "MN",
"postal_code": "554344147",
"telephone_number": "763-755-1330",
"fax_number": "763-755-4305"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MCLELLAN",
"first_name": "CORINE",
"middle_name": "NICOLE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-12-07",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "MN",
"license": "D11538",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Blaine, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.