Healthcare Provider Details

I. General information

NPI: 1316014202
Provider Name (Legal Business Name): ST JOSEPHS COMMUNITY DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PLEASANT AVE S
PARK RAPIDS MN
56470-1434
US

IV. Provider business mailing address

205 PLEASANT AVE S
PARK RAPIDS MN
56470-1434
US

V. Phone/Fax

Practice location:
  • Phone: 218-732-4436
  • Fax: 218-732-1119
Mailing address:
  • Phone: 218-732-4436
  • Fax: 218-732-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number StateMN

VIII. Authorized Official

Name: MRS. AMY MORRIS
Title or Position: CLINIC MANAGER
Credential:
Phone: 218-237-5469