Provider Demographics
NPI:1659660298
Name:ST. ANTHONY VILLAGE DENTAL CARE, P.A.
Entity Type:Organization
Organization Name:ST. ANTHONY VILLAGE DENTAL CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:B
Authorized Official - Last Name:OSTERBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-781-9270
Mailing Address - Street 1:2525 33RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1539
Mailing Address - Country:US
Mailing Address - Phone:612-781-9270
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10494261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental