Healthcare Provider Details

I. General information

NPI: 1689952038
Provider Name (Legal Business Name): EAGLE LAKE FAMILY DENTISTRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 2ND AVE S
SAINT JAMES MN
56081-1737
US

IV. Provider business mailing address

504 2ND AVE S PO BOX 515
SAINT JAMES MN
56081-1737
US

V. Phone/Fax

Practice location:
  • Phone: 507-375-4611
  • Fax: 507-375-4989
Mailing address:
  • Phone: 507-375-4611
  • Fax: 507-375-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11770
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12980
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9088
License Number StateMN

VIII. Authorized Official

Name: DR. SEAN PATRICK VOSTAD
Title or Position: DENTIST
Credential: DDS
Phone: 507-257-3800