Provider Demographics
NPI:1043642135
Name:ST PAUL FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ST PAUL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:STANTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-488-5522
Mailing Address - Street 1:1050 LARPENTEUR AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6556
Mailing Address - Country:US
Mailing Address - Phone:651-488-5522
Mailing Address - Fax:651-488-0944
Practice Address - Street 1:1050 LARPENTEUR AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-6556
Practice Address - Country:US
Practice Address - Phone:651-488-5522
Practice Address - Fax:651-488-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8140122300000X
MN10691122300000X
MND12450122300000X
MND13219122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty