Provider Demographics
NPI:1952709420
Name:ST. CROIX ENDODONTICS
Entity Type:Organization
Organization Name:ST. CROIX ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-767-9119
Mailing Address - Street 1:25 LAKE ST N
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2535
Mailing Address - Country:US
Mailing Address - Phone:651-464-7388
Mailing Address - Fax:651-982-6236
Practice Address - Street 1:25 LAKE ST N
Practice Address - Street 2:SUITE 110
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2535
Practice Address - Country:US
Practice Address - Phone:651-464-7388
Practice Address - Fax:651-982-6236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty