1487847752 NPI number — ENDODONTIC PROFESSIONALS PA ST CLOUD ENDODONTICS

Table of content: (NPI 1487847752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487847752 NPI number — ENDODONTIC PROFESSIONALS PA ST CLOUD ENDODONTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENDODONTIC PROFESSIONALS PA ST CLOUD ENDODONTICS
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:
1487847752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1555 NORTHWAY DRIVE
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
ST CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-259-5078
Provider Business Mailing Address Fax Number:
320-259-1484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 NORTHWAY DRIVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
ST CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-259-5078
Provider Business Practice Location Address Fax Number:
320-259-1484
Provider Enumeration Date:
08/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KARN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
320-259-5078

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  8575456 , 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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