Healthcare Provider Details

I. General information

NPI: 1013386796
Provider Name (Legal Business Name): SYDLEWSKI ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 7TH ST W STE 102
SAINT PAUL MN
55102-4252
US

IV. Provider business mailing address

2126 5TH ST
WHITE BEAR LAKE MN
55110-2717
US

V. Phone/Fax

Practice location:
  • Phone: 651-426-9986
  • Fax:
Mailing address:
  • Phone: 651-426-9986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH REID RAASCH
Title or Position: FINANCIAL COODINATOR
Credential:
Phone: 651-426-9986