Provider Demographics
NPI:1508080532
Name:STONE CREEK DENTAL, P.A.
Entity Type:Organization
Organization Name:STONE CREEK DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:MAJA
Authorized Official - Last Name:AXEL-WEYANDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-937-2839
Mailing Address - Street 1:7935 STONE CREEK DR
Mailing Address - Street 2:STE. 150
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4610
Mailing Address - Country:US
Mailing Address - Phone:952-937-2839
Mailing Address - Fax:952-401-3307
Practice Address - Street 1:7935 STONE CREEK DR
Practice Address - Street 2:STE. 150
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4610
Practice Address - Country:US
Practice Address - Phone:952-937-2839
Practice Address - Fax:952-401-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11335122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty