MEDICARE: WEST ST PAUL FAMILY DENTISTY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1043654411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST ST PAUL FAMILY DENTISTY PLLC

Provider Business Mailing Address
First Line	:	250 WENTWORTH AVE E
Second Line	:
City	:	WEST ST PAUL
State	:	MN
Zip	:	55118-3507
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 WENTWORTH AVE E
Second Line	:
City	:	WEST ST PAUL
State	:	MN
Zip	:	55118-3507
Country	:	US
Telephone Number	:	651-455-1577
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	PHILLIP ZHAN
Credential	:
Telephone Number	:	952-432-7145

Provider Enumeration Date	:	04/29/2013
Last Update Date	:	04/29/2013

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