1265873707 NPI number — CENTRAL MINNESOTA PEDIATRIC DENTISTS PA

Table of content: (NPI 1265873707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265873707 NPI number — CENTRAL MINNESOTA PEDIATRIC DENTISTS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL MINNESOTA PEDIATRIC DENTISTS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265873707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 CENTRACARE CIR STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-253-0272
Provider Business Mailing Address Fax Number:
320-251-2661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
570 HUMBOLDT DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIG LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55309-4844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-253-0272
Provider Business Practice Location Address Fax Number:
320-251-2661
Provider Enumeration Date:
07/12/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STEIL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PARTNER/OWNER
Authorized Official Telephone Number:
320-253-0272

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D7765 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: D11073 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X , with the licence number: D11344 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: D12885 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)