Provider Demographics
NPI:1558431890
Name:DENTAL SOUTH PA
Entity Type:Organization
Organization Name:DENTAL SOUTH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PRUEHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-451-1277
Mailing Address - Street 1:800 MARIE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075
Mailing Address - Country:US
Mailing Address - Phone:651-451-1277
Mailing Address - Fax:651-455-8488
Practice Address - Street 1:800 MARIE AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075
Practice Address - Country:US
Practice Address - Phone:651-451-1277
Practice Address - Fax:651-455-8488
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL SOUTH PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-08
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9619122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty