Provider Demographics
NPI:1629066840
Name:OVALLE, SAUL (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:SAUL
Middle Name:
Last Name:OVALLE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 BURNETT LN
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1661
Mailing Address - Country:US
Mailing Address - Phone:507-387-8220
Mailing Address - Fax:
Practice Address - Street 1:212 STAR ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4825
Practice Address - Country:US
Practice Address - Phone:507-387-4078
Practice Address - Fax:507-387-4055
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND117271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41730WAOtherBLUE PLUS GROUP NUMBER