Provider Demographics
NPI:1851364392
Name:CHAVEZ, JULIE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:A
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5100 GAMBLE DR
Mailing Address - Street 2:SUITE 125
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1521
Mailing Address - Country:US
Mailing Address - Phone:952-465-0105
Mailing Address - Fax:952-465-0106
Practice Address - Street 1:5100 GAMBLE DR
Practice Address - Street 2:SUITE 125
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1521
Practice Address - Country:US
Practice Address - Phone:952-465-0105
Practice Address - Fax:952-465-0106
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MND113991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN140122OtherU CARE
MN850000116OtherMEDICARE PTAN
MN000924472OtherUNITED CONCORDIA
MNP00841569OtherMEDICARE RAILROAD PTAN
MN3AI38CHOtherBLUE CROSS BLUE SHIELD
MN15306OtherDORAL/DENTAQUEST