Provider Demographics
NPI:1073787669
Name:SEDATION & IMPLANT DENTISTRY
Entity Type:Organization
Organization Name:SEDATION & IMPLANT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:ANDRESON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-735-4661
Mailing Address - Street 1:1815 SUBURBAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4302
Mailing Address - Country:US
Mailing Address - Phone:651-735-4661
Mailing Address - Fax:651-735-1910
Practice Address - Street 1:1815 SUBURBAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4302
Practice Address - Country:US
Practice Address - Phone:651-735-4661
Practice Address - Fax:651-735-1910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND70911223G0001X
MND97661223G0001X
MND92081223P0300X
MND122281223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty