Healthcare Provider Details

I. General information

NPI: 1114188307
Provider Name (Legal Business Name): PEPIN VALLEY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 N 7TH ST
LAKE CITY MN
55041-1251
US

IV. Provider business mailing address

1350 N 7TH ST
LAKE CITY MN
55041-1251
US

V. Phone/Fax

Practice location:
  • Phone: 651-345-3023
  • Fax: 651-345-3064
Mailing address:
  • Phone: 651-345-3023
  • Fax: 651-345-3064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9591
License Number StateMN

VIII. Authorized Official

Name: STEPHEN BROWN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 651-345-3023