Healthcare Provider Details

I. General information

NPI: 1285865006
Provider Name (Legal Business Name): WAYNE O SLETTEN DDS MSD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 W FRONT ST
ALBERT LEA MN
56007-1903
US

IV. Provider business mailing address

1206 W FRONT ST
ALBERT LEA MN
56007-1903
US

V. Phone/Fax

Practice location:
  • Phone: 507-373-1915
  • Fax: 507-373-1254
Mailing address:
  • Phone: 507-373-1915
  • Fax: 507-373-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7015
License Number StateMN

VIII. Authorized Official

Name: WAYNE ORVILLE SLETTEN
Title or Position: OWNER
Credential: D.D.S.
Phone: 507-373-1915