Healthcare Provider Details

I. General information

NPI: 1013153352
Provider Name (Legal Business Name): ASSOCIATED DENTISTS SHOLOM HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 7TH ST W SUITE B
SAINT PAUL MN
55102-4205
US

IV. Provider business mailing address

1371 7TH ST W SUITE B
SAINT PAUL MN
55102-4205
US

V. Phone/Fax

Practice location:
  • Phone: 651-488-5557
  • Fax: 651-488-0014
Mailing address:
  • Phone: 651-488-5557
  • Fax: 651-488-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11152
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11202
License Number StateMN

VIII. Authorized Official

Name: ANGIE LOFT
Title or Position: SITE MANAGER
Credential:
Phone: 651-488-5557