Healthcare Provider Details

I. General information

NPI: 1205856713
Provider Name (Legal Business Name): DALE HERBERT VANCIL D. P, M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DALE HERBERT VANCIL D.P.M.

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 WILLOW LAKE BLVD. SUITE 300
LINO LAKES MN
55110-5152
US

IV. Provider business mailing address

3485 WILLOW LAKE BLVD SUITE 300
SAINT PAUL MN
55110-5152
US

V. Phone/Fax

Practice location:
  • Phone: 651-765-8200
  • Fax: 651-765-8201
Mailing address:
  • Phone: 651-765-8200
  • Fax: 651-765-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number338
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: