Provider Demographics
NPI:1407130453
Name:SENTINEL LASER CENTER, P.A.
Entity Type:Organization
Organization Name:SENTINEL LASER CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-287-8781
Mailing Address - Street 1:514 SAINT PETER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1001
Mailing Address - Country:US
Mailing Address - Phone:651-287-8781
Mailing Address - Fax:651-287-8782
Practice Address - Street 1:514 SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1001
Practice Address - Country:US
Practice Address - Phone:651-287-8781
Practice Address - Fax:651-287-8782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21358207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty