Provider Demographics
NPI:1487868113
Name:CHRYSTAL, SALLY POPE (DDS)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:POPE
Last Name:CHRYSTAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4581 MCDONALD DRIVE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2147
Mailing Address - Country:US
Mailing Address - Phone:651-439-8872
Mailing Address - Fax:
Practice Address - Street 1:6949 VALLEY CREEK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2253
Practice Address - Country:US
Practice Address - Phone:651-731-1054
Practice Address - Fax:651-731-2183
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10862122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist