Provider Demographics
NPI:1184878431
Name:ST. CROIX VALLEY DENTAL
Entity type:Organization
Organization Name:ST. CROIX VALLEY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-439-2600
Mailing Address - Street 1:14643 MERCANTILE DR N
Mailing Address - Street 2:SUITE 113
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-4552
Mailing Address - Country:US
Mailing Address - Phone:651-407-0999
Mailing Address - Fax:
Practice Address - Street 1:14643 MERCANTILE DR N
Practice Address - Street 2:SUITE 113
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-4552
Practice Address - Country:US
Practice Address - Phone:651-407-0999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty