Provider Demographics
NPI:1528535788
Name:SAINT ANTHONY VILLAGE DENTISTRY
Entity Type:Organization
Organization Name:SAINT ANTHONY VILLAGE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-789-2853
Mailing Address - Street 1:1632 WASHINGTON ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1336
Mailing Address - Country:US
Mailing Address - Phone:612-789-2853
Mailing Address - Fax:612-767-9430
Practice Address - Street 1:2525 33RD AVE NE
Practice Address - Street 2:
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-1539
Practice Address - Country:US
Practice Address - Phone:612-781-9270
Practice Address - Fax:612-767-3490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental