Active NPI
Jeremy Derksen, DDS
- General Practice Dentistry
- Roseville, MN
National Provider Identifier
1740573443
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- D12937
- Practice address
- 185 McCarrons Blvd N #316
Roseville, MN 55113 - Phone
- (515) 326-5977
- NPI assigned
- May 27, 2011
- Last updated
- May 27, 2011
- Sex
- Male
- Sole proprietor
- Yes
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 | D12937 | MN | Primary |
Addresses
Primary practice location
185 McCarrons Blvd N #316
Roseville, MN 55113
Mailing address
185 McCarrons Blvd N #316
Roseville, MN 55113
Phone (515) 326-5977
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160415000743 | MN | Order and Referring Only - Oral Surgery | 2163720780 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D12937 | MN | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1306454400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1306454400000",
"number": "1740573443",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "185 MCCARRONS BLVD N #316",
"city": "ROSEVILLE",
"state": "MN",
"postal_code": "55113",
"telephone_number": "515-326-5977"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "185 MCCARRONS BLVD N #316",
"city": "ROSEVILLE",
"state": "MN",
"postal_code": "55113",
"telephone_number": "515-326-5977"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DERKSEN",
"first_name": "JEREMY",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2011-05-27",
"last_updated": "2011-05-27",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "MN",
"license": "D12937",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Roseville, MN
- Dental Specialist of Minnesota, PLLC (The Dental Specialists Roseville PEDS)
- Dental Specialists of Minnesota, PLLC
- Dental Specialists of Minnesota, PLLC (The Dental Specialists)
- Dental Specialists of Minnesota, PLLC
- Lisa Denzer, LPPC
- Leah May Deshepper, RN
- Designing Smiles, PA
- Brenda Deutsch, NP
- Jane Shelgren Diamond, MSW
- Chelsea A Dick, RN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 27, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.