Provider Demographics
NPI:1508318247
Name:TRACY M. ST. DENNIS, D.D.S., PLLC
Entity Type:Organization
Organization Name:TRACY M. ST. DENNIS, D.D.S., PLLC
Other - Org Name:WILLOW LAKE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ST DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-341-2106
Mailing Address - Street 1:3475 WILLOW LAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5156
Mailing Address - Country:US
Mailing Address - Phone:651-341-2106
Mailing Address - Fax:
Practice Address - Street 1:3475 WILLOW LAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-5156
Practice Address - Country:US
Practice Address - Phone:651-341-2106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental