Provider Demographics
NPI:1275318628
Name:FOUNDATIONS PSA LLC
Entity Type:Organization
Organization Name:FOUNDATIONS PSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-955-4300
Mailing Address - Street 1:1635 SUNNYBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:MINNETRISTA
Mailing Address - State:MN
Mailing Address - Zip Code:55364-1276
Mailing Address - Country:US
Mailing Address - Phone:612-387-5009
Mailing Address - Fax:
Practice Address - Street 1:126 PIONEER TRL
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1167
Practice Address - Country:US
Practice Address - Phone:952-472-7738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-25
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty