Provider Demographics
NPI:1083131643
Name:PRIOR LAKE
Entity Type:Organization
Organization Name:PRIOR LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:SARLES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-447-1080
Mailing Address - Street 1:14120 COMMERCE AVE NE STE 300
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1503
Mailing Address - Country:US
Mailing Address - Phone:952-447-1080
Mailing Address - Fax:952-447-0376
Practice Address - Street 1:14120 COMMERCE AVE
Practice Address - Street 2:SUITE #300
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-5537
Practice Address - Country:US
Practice Address - Phone:952-447-1080
Practice Address - Fax:952-447-0376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13230261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental