Healthcare Provider Details

I. General information

NPI: 1407130453
Provider Name (Legal Business Name): SENTINEL LASER CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 SAINT PETER ST
SAINT PAUL MN
55102-1001
US

IV. Provider business mailing address

514 SAINT PETER ST
SAINT PAUL MN
55102-1001
US

V. Phone/Fax

Practice location:
  • Phone: 651-287-8781
  • Fax: 651-287-8782
Mailing address:
  • Phone: 651-287-8781
  • Fax: 651-287-8782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number21358
License Number StateMN

VIII. Authorized Official

Name: STACY LEE DAVISON
Title or Position: ACCOUNTS MANAGER
Credential:
Phone: 651-287-8781