Provider Demographics
NPI:1013153352
Name:ASSOCIATED DENTISTS SHOLOM HOME
Entity Type:Organization
Organization Name:ASSOCIATED DENTISTS SHOLOM HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SITE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-488-5557
Mailing Address - Street 1:1371 7TH ST W
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4205
Mailing Address - Country:US
Mailing Address - Phone:651-488-5557
Mailing Address - Fax:651-488-0014
Practice Address - Street 1:1371 7TH ST W
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4205
Practice Address - Country:US
Practice Address - Phone:651-488-5557
Practice Address - Fax:651-488-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11152122300000X
MND112021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty