Provider Demographics
NPI: | 1245416403 |
---|---|
Name: | SNELLING AVENUE DENTAL |
Entity Type: | Organization |
Organization Name: | SNELLING AVENUE DENTAL |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CHARLENE |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | SAICE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 651-699-5600 |
Mailing Address - Street 1: | 604 SNELLING AVE S |
Mailing Address - Street 2: | |
Mailing Address - City: | SAINT PAUL |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55116-1528 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 651-699-5600 |
Mailing Address - Fax: | 651-699-1966 |
Practice Address - Street 1: | 604 SNELLING AVE S |
Practice Address - Street 2: | |
Practice Address - City: | SAINT PAUL |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55116-1528 |
Practice Address - Country: | US |
Practice Address - Phone: | 651-699-5600 |
Practice Address - Fax: | 651-699-1966 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-01-17 |
Last Update Date: | 2008-06-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 7662 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |