1912163270 NPI number — ARTISTIC SMILE DENTAL CENTER PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912163270 NPI number — ARTISTIC SMILE DENTAL CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARTISTIC SMILE DENTAL CENTER PLLC
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:
6
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:
1912163270
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417 13TH AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-1666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-203-7373
Provider Business Mailing Address Fax Number:
320-257-5859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 2ND ST S
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-2133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-203-7373
Provider Business Practice Location Address Fax Number:
320-257-5859
Provider Enumeration Date:
08/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BASSAS
Authorized Official First Name:
SAAD
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
320-203-7373

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  11850 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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