Provider Demographics
NPI:1891419818
Name:SALO DENTAL
Entity Type:Organization
Organization Name:SALO DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-557-6893
Mailing Address - Street 1:3900 VINEWOOD LN N STE 13
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55441-1155
Mailing Address - Country:US
Mailing Address - Phone:763-557-6893
Mailing Address - Fax:
Practice Address - Street 1:3900 VINEWOOD LN N STE 13
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55441-1155
Practice Address - Country:US
Practice Address - Phone:763-557-6893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND10976OtherDENTAL LICENSE