Healthcare Provider Details

I. General information

NPI: 1245416403
Provider Name (Legal Business Name): SNELLING AVENUE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 SNELLING AVE S
SAINT PAUL MN
55116-1528
US

IV. Provider business mailing address

604 SNELLING AVE S
SAINT PAUL MN
55116-1528
US

V. Phone/Fax

Practice location:
  • Phone: 651-699-5600
  • Fax: 651-699-1966
Mailing address:
  • Phone: 651-699-5600
  • Fax: 651-699-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7662
License Number StateMN

VIII. Authorized Official

Name: CHARLENE M SAICE
Title or Position: OFFICE MANAGER
Credential:
Phone: 651-699-5600