Provider Demographics
NPI:1124386099
Name:SJULSON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SJULSON FAMILY DENTISTRY
Other - Org Name:DR. SJULSON'S DENTAL OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SJULSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-435-1599
Mailing Address - Street 1:109 JOHNSON AVE N.
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-1327
Mailing Address - Country:US
Mailing Address - Phone:218-435-1599
Mailing Address - Fax:218-435-6568
Practice Address - Street 1:109 JOHNSON AVE. N
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1327
Practice Address - Country:US
Practice Address - Phone:218-435-1599
Practice Address - Fax:218-435-6568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8437122300000X
MNLGL5122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty