Healthcare Provider Details

I. General information

NPI: 1831857788
Provider Name (Legal Business Name): SEDATION AND IMPLANT DENSTISTRY - DR ANDERSON AND DR YANG PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 SUBURBAN AVE STE 200
SAINT PAUL MN
55119-4380
US

IV. Provider business mailing address

1815 SUBURBAN AVE STE 200
SAINT PAUL MN
55119-4380
US

V. Phone/Fax

Practice location:
  • Phone: 651-735-4661
  • Fax: 651-735-4661
Mailing address:
  • Phone: 651-735-4661
  • Fax: 651-735-4661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DARA THAO
Title or Position: OFFICE MANAGER
Credential:
Phone: 651-735-4661