Provider Demographics
NPI:1437704020
Name:GRAND AVENUE SMILES
Entity Type:Organization
Organization Name:GRAND AVENUE SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHVETA
Authorized Official - Middle Name:
Authorized Official - Last Name:SETIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-383-5878
Mailing Address - Street 1:5647 MATTERHORN DR NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432
Mailing Address - Country:US
Mailing Address - Phone:612-383-5878
Mailing Address - Fax:
Practice Address - Street 1:1845 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105
Practice Address - Country:US
Practice Address - Phone:651-690-5262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty