Provider Demographics
NPI:1043870645
Name:ST PAUL ORAL SURGERY AND DENTAL IMPLANTS LLC
Entity Type:Organization
Organization Name:ST PAUL ORAL SURGERY AND DENTAL IMPLANTS LLC
Other - Org Name:ST. PAUL ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 115N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1097
Mailing Address - Country:US
Mailing Address - Phone:651-645-6429
Mailing Address - Fax:651-645-8326
Practice Address - Street 1:2550 UNIVERSITY AVE W STE 115N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1097
Practice Address - Country:US
Practice Address - Phone:651-645-6429
Practice Address - Fax:651-645-8326
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST PAUL ORAL SURGERY AND DENTAL IMPLANTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-17
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty