Healthcare Provider Details

I. General information

NPI: 1275318628
Provider Name (Legal Business Name): FOUNDATIONS PSA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 PIONEER TRL
CHASKA MN
55318-1167
US

IV. Provider business mailing address

1635 SUNNYBROOK CIR
MINNETRISTA MN
55364-1276
US

V. Phone/Fax

Practice location:
  • Phone: 952-472-7738
  • Fax:
Mailing address:
  • Phone: 612-387-5009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHANIE MINER
Title or Position: OWNER
Credential: DDS
Phone: 952-955-4300