Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | D11484 | MN |
NPI | 1003975061 |
---|---|
Provider Name | Dr. Kirk Roland Baumgardner |
First Address | Oakdale, MN 55128-5369 |
Second Address | Roseville, MN 55113-1352 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2006 |
Last Update Date | 08/07/2007 |