Healthcare Provider Details

I. General information

NPI: 1639733389
Provider Name (Legal Business Name): STONE GATE DENTAL ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 NORTHWAY DR STE 108
SAINT CLOUD MN
56303-4490
US

IV. Provider business mailing address

1521 NORTHWAY DR STE 108
SAINT CLOUD MN
56303-4490
US

V. Phone/Fax

Practice location:
  • Phone: 320-250-5540
  • Fax:
Mailing address:
  • Phone: 320-250-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN MICHAEL COLLIER
Title or Position: OWNER
Credential: DDS
Phone: 320-250-5540