Healthcare Provider Details

I. General information

NPI: 1922526334
Provider Name (Legal Business Name): ALL SMILES DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 CLYDESDALE TRL
MEDINA MN
55340-4513
US

IV. Provider business mailing address

8812 138TH ST W
SAVAGE MN
55378-3130
US

V. Phone/Fax

Practice location:
  • Phone: 952-239-5072
  • Fax:
Mailing address:
  • Phone: 952-239-5951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11353
License Number StateMN

VIII. Authorized Official

Name: NAM PHAM
Title or Position: CEO
Credential:
Phone: 952-239-5072