Provider Demographics
NPI:1043471337
Name:NICOLLET 38TH ST DENTAL
Entity Type:Organization
Organization Name:NICOLLET 38TH ST DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-825-7835
Mailing Address - Street 1:17 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-1341
Mailing Address - Country:US
Mailing Address - Phone:612-825-7835
Mailing Address - Fax:612-825-3819
Practice Address - Street 1:17 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-1341
Practice Address - Country:US
Practice Address - Phone:612-825-7835
Practice Address - Fax:612-825-3819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND90051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN143320200OtherMA
MN156718700OtherNPI DR SIMS
MN1568465441OtherNPI DR WILLIAMS
MN1174638613OtherNPI DR WARREN
MN156718700OtherMA