Healthcare Provider Details

I. General information

NPI: 1265873707
Provider Name (Legal Business Name): CENTRAL MINNESOTA PEDIATRIC DENTISTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 HUMBOLDT DR STE 102
BIG LAKE MN
55309-4844
US

IV. Provider business mailing address

1900 CENTRACARE CIR STE 350
SAINT CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-0272
  • Fax: 320-251-2661
Mailing address:
  • Phone: 320-253-0272
  • Fax: 320-251-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD7765
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD11073
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD11344
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD12885
License Number StateMN

VIII. Authorized Official

Name: DR. MICHAEL W STEIL
Title or Position: PARTNER/OWNER
Credential: DDS
Phone: 320-253-0272