Provider Demographics
NPI:1780095828
Name:DR.CRANDALL D.D.S
Entity type:Organization
Organization Name:DR.CRANDALL D.D.S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-429-5354
Mailing Address - Street 1:2300 HIGHWAY 96 E
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2620
Mailing Address - Country:US
Mailing Address - Phone:651-429-5354
Mailing Address - Fax:651-653-0981
Practice Address - Street 1:2300 HIGHWAY 96 E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2620
Practice Address - Country:US
Practice Address - Phone:651-429-5354
Practice Address - Fax:651-653-0981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6428122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty