Healthcare Provider Details

I. General information

NPI: 1407973605
Provider Name (Legal Business Name): CHILDRENS DENTAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 BROADWAY ST. NE
MINNEAPOLIS MN
55413
US

IV. Provider business mailing address

636 BROADWAY ST. NE
MINNEAPOLIS MN
55413
US

V. Phone/Fax

Practice location:
  • Phone: 612-746-1530
  • Fax: 612-746-1531
Mailing address:
  • Phone: 612-746-1530
  • Fax: 612-746-1531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SARAH WOVCHA
Title or Position: EXECUTIVE DIRECTOR
Credential: J.D., M.P.H
Phone: 612-636-1577