Provider Demographics
NPI:1497991798
Name:NORTH ST. PAUL DENTAL
Entity Type:Organization
Organization Name:NORTH ST. PAUL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-770-6260
Mailing Address - Street 1:814 MAHTOMEDI AVE
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1730
Mailing Address - Country:US
Mailing Address - Phone:651-426-0011
Mailing Address - Fax:651-426-2075
Practice Address - Street 1:2082 11TH AVE E
Practice Address - Street 2:
Practice Address - City:NORTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-5112
Practice Address - Country:US
Practice Address - Phone:651-770-6260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAHTOMEDI DENTAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN82171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN982017500Medicaid